by Jared Hecht (blog, linkedin, twitter)
ToC
TLDR
Why am I doing this?
Background
Perverse Incentives
What is heart disease?
Preventing Disease
How to not die of heart disease
The Current State of Affairs
What To Do
Biomarkers
Imaging Diagnostics
Treatment
Medication
Behavioral
Don’t Die!
How to get this from your doctor
What should you do with your test results?
Final Thoughts
- You should be scared of heart disease. Heart disease is the leading cause of death globally, and it’s not just an old people problem. 25% of heart attacks occur in people under the age of 55.
- The first sign of heart disease for many people is they drop dead of a heart attack. It’s a quiet disease that develops silently over many decades and then suddenly appears when it kills you.
- You don’t have to die of heart disease if you don’t want to.
- The way really rich people avoid dying of heart disease is they go to very expensive high-end concierge doctors who focus on preventative medicine (i.e. practitioners who help you prevent getting sick in the first place).
- But the things they do to avoid heart disease are simple and accessible to everyone. Instead of paying tens of thousands of dollars a year to see these expensive concierge doctors, you can actually do all the most important tests yourself for less than $300, and most medications you’d need should be covered by insurance.
- We have all the knowledge, testing, diagnostics, and treatments to prevent heart disease and you can follow this instruction manual to start taking your heart health into your own hands.
- The best time to make the decision to not die of heart disease and start taking action is in your 30s and 40s.
- You cannot rely on your doctor to help you prevent heart disease or a heart attack. They are there to help you when you’re sick with heart disease or if you survive your first heart attack. You are the only person who can prevent yourself from dying of heart disease. The good news is, it’s pretty darn easy.
- If you only read one thing here, make it the “How to not die of heart disease” section.
- You can read my first post about heart disease here to see where it got started, and more about why I published this here. You can also download the PDF version here.
- If you are building or want to build something in this space and help people not die of heart disease, please email me at [email protected].
One thing I’ve learned through experience is that nobody has your back in the healthcare system. You need to be your own Advocate. I want to help people become their own Advocate and put their heart health in their own hands.
In early 2023 during a routine skin check at my dermatologist, I uncovered a basal-cell carcinoma. It’s a benign form of skin cancer. I freaked out. For the first time in my life I began to seriously think about my own mortality. I have two young children and I want to be there for them as they get old and be an engaged grandfather and all that amazing stuff. I don’t want to die young and have them grow up fatherless.
So I did the cliche thing every tech-entrepreneur-dude does: I signed up for a very expensive high-end concierge medicine service. This is an extraordinary privilege. I wanted to cover my bases, make sure nothing else was wrong with me, and do my best to understand how to stay healthy and protect against anything that could conceivably kill me while being relatively young. I wanted to control the things I could control.
The first thing that this high-end concierge practice did was evaluate my heart health. I thought my heart was totally fine. Previously, I would visit my primary care physician (PCP) twice a year and get my bloodwork done annually. Here’s what my last standard lipid panel (a standard cardiometabolic test conducted by most physicians) from my PCP looked like:
The results told me my LDL-C was fine, and my doctor said I didn’t need to take any additional preventative measures. I should simply maintain whatever it was I had been doing (e.g. exercising and eating somewhat healthy). This was from Forward Health - a tech-forward company that attempted to be a better version of One Medical. I shared these results with a leading lipidologist who proclaimed: “Not sure if the lab or the primary care doc said an LDL-C of 116 mg/dL was fine but that concentration is the 50th percentile population cut point in the MESA study and should never ever be considered as normal.”
When I signed up for concierge medicine, the first thing they did was an extended lipid panel - a more extensive test that measures more important biomarkers like ApoB and Lp(a). I was shocked when my results came back:
I learned that my ApoB (Apoliproprotein B) is not good. (It’s also important to note that, according to a lipidologist friend, an ApoB of 96 is at a totally unacceptable 50th percentile population cutpoint from Framingham Offspring Study.) I needed to get it lower. This test showed that if I continued on my trajectory, I would likely suffer from heart disease over time. This test also told me I don’t suffer from bad Lp(a) - that was a relief. As a result of my high ApoB and moderate LDL-C, my doctor immediately prescribed a statin and said I should get a CTA scan to detect any existing heart disease. My CTA scan confirmed that I had calcified plaque in my arteries (ie, heart disease). (By the way, I’ll get to what all of these fancy acronyms mean soon. Don’t worry if you don’t know what they are - I didn’t know either.)
Comparing and contrasting these two experiences was profoundly insightful for me. My PCP (primary care physician) was following standard guidelines and proclaimed that based on my results I was “totally okay.” He was not looking for more important biomarkers like ApoB or Lp(a) or Hs-CRP. I could go on my merry way and do my thing. But my expensive concierge doctor showed me I had early-stage heart disease, needed to be on a statin to lower my ApoB, and that if I kept doing whatever I was doing, I’d grow increasingly more at risk of dying of heart disease. Since then, I’ve course-corrected and taken my heart health seriously. It’s something I work on every day and it’s reflected in the medications I take, the tests I get, the food I eat, and the way I live my life. I’ve made the conscious decision to not die of heart disease.
I quickly realized that I didn’t need to sign up for an expensive concierge service to get these tests done. If I had known more about heart health beforehand, I could have asked (well, really demanded) my PCP to order these tests for me. When it comes to heart health, the tests you need to understand the most important biomarkers and whether or not you have disease (via imaging) are affordable for most people. We are talking $80 or so of blood tests twice annually and a one-time $150 imaging test that needs to be done every one to five years depending on your results. You don’t have to be rich to protect your heart the exact same way many billionaires and millionaires do. As far as preventative health goes, it’s easy, and my goal with this is to provide the knowledge, tools, and playbook to help you take control of your heart health the same way an elite billionaire would. For almost everyone, you don’t have to die of heart disease if you don’t want to.
The other reason I am doing this is because it’s critical that people be their own Advocate when they navigate the health system, and I want this to be a tool for everyone to do exactly that. What does being your own Advocate mean? I learned the term Advocate from my father-in-law who is a retired gastroenterologist. After we had our first child, my wife suffered from complications from a c-section. We were tied up in the hospital for over a week, and it was unclear whether we’d all make it home together. We were at one of the best hospitals in the country, but the attention we received from attending doctors and nurses was pretty frightening. Hours would go by between visits. They’d prescribe medications only to have them filled the following day. I quickly grew frustrated and realized that we needed to fight to take care of ourselves and find the right balance of being aggressively pushy and likable to the doctors and nurses. Even in hospitals where you think you are supposed to be taken care of every step of the way, you still need to fight for yourself and your loved ones. When I told my father-in-law about what was happening and that I was worried I was being too demanding, he told me I was doing the right thing by being our family’s Advocate, and that every doctor who is admitted to a hospital knows to do this if they want to receive quality care.
I experienced this repeatedly. We were admitted to the hospital for over a week when my daughter contracted viral meningitis (the scariest experience of my life). Even while working with incredible infectious disease doctors, I still had to fight and constantly remind people what the next steps were during our admission. Nobody is watching over you - it’s your job to organize things and ensure they’re on track. I had to coordinate between the infectious disease departments and neurology departments and make sure the people doing the lumbar puncture on my 9-month-old daughter weren’t just residents practicing on my child but experts who had conducted the procedure countless times before. You must Advocate for yourself and the ones you love.
While doctors may have the best of intentions and have in many ways engaged in one of the noblest of professions, they cannot and do not take care of you as well as you can take care of yourself. We are participating in a healthcare system that is incentivized to prioritize making money as opposed to keeping us healthy and out of the system in the first place. You need to fight for yourself. This guide is intended to help you fight for your heart.
I am also doing this because, like any child, there’s something deep down inside of me that wants to make my parents proud. Both of my parents are doctors. My mother was an internist for many years and my father was a cardiologist. He spent almost the entirety of his career trying to convince people they didn’t have to die of heart disease, and that we could use new technologies, namely CT and CTA scans, to detect and treat heart disease. His quest was initially met with resistance, but over time people converted, and now every cardiologist who understands anything about heart disease believes in what my father fought for, and they know his name and the work that he has done. He is widely published and has taught a new generation of cardiologists best practices when it comes to using imaging to detect and understand heart disease. There’s a piece of me that wants to help progress his work and bring what he has shared with the medical world to the broader patient population.
I’m a technology investor and entrepreneur, and believe we need a consumer facing company that is specifically dedicated to helping people not die of heart disease. I think you can do a lot of good in the world and build something quite meaningful by focusing on this problem. I have an idea of what the product and service looks like, but the thing I am questioning is how many people actually care about this? And care enough about it to actually do something. Of course we don’t want to die of something that’s totally avoidable, but heart disease is not something we experience every day. When we do experience it it’s because we either drop dead of a heart attack, have a near-death scare from a heart attack, or know someone in our family or friend group who suffered from a heart attack. We don’t think about it daily, and taking care of ourselves requires preventative measures that most people either don’t have the time to do or they just don’t want to prioritize. I get that completely. These services can also be expensive (although I am convinced a heart focused one can be delivered in an affordable way to millions of people). So part of my motivation is to actually see how many people care about this. How many people will read this? How many people will take the simple steps to avoid heart disease? And how many people would be interested in a service that makes taking these steps seamless and easy and affordable? I don’t know the answers to those questions, and I want to help figure them out.
What I do know is that whenever I talk about this with friends, their eyes light up. Particularly friends in their 30s and 40s who have recently had children and now think about their own mortality. They’re all interested in this, but I’ve been disappointed that only a minority of them have actually taken the requisite steps that I’ve learned about and recommend in this guide. I hope that changes. I’m an optimist, so I think it will. Today when I was dropping my children off at school, a fellow parent and entrepreneur told me he read an article I wrote about heart disease and called his doctor and is getting tested. That gave me hope. Interactions like that make me believe this is a worthwhile endeavor.
At the very least, I hope this guide is informative and helps you or someone you love avoid dying from heart disease.
Heart disease is the leading cause of death globally. It is the thing that kills more people on Planet Earth every year than anything else for both men and women.
It’s not just an old-people problem. 25% of heart attacks occur in people younger than 54 years of age. This is a staggering statistic unknown to most, including primary care physicians! That percentage continues to grow over time as the general population becomes increasingly less healthy (ie, sedentary, obese, poor diet, etc.). For all the damage heart disease inflicts on people’s lives and our health systems, it receives very little attention. Take a look at how frequently population killers are covered by the media:
It’s not sexy, and as a result, an overwhelming majority of the population is unaware of how to avoid succumbing to it. I think that’s super messed up and needs to change.
The thing about heart disease is that we have all the tools to make it a nonentity and remove it from the Top 10 leading causes of death. Unfortunately, for a whole host of reasons, our primary care physicians are neither equipped or incentivized to lead the charge on fixing the problem. More often than not the first sign that someone has heart disease is they drop dead of a heart attack. And by the time fortunate patients who don’t drop dead approach their doctor about chest pain or other symptoms (eg shortness of breath with exertion, palpitations, vague dizziness, and fatigue) and are referred to a cardiologist, that cardiologist is going to wish you had visited them five years ago. Atherosclerosis is a disease that slowly builds over decades, so the best way to really avoid dying from it is to start getting educated and taking action in your late 20s, 30s, and 40s.
Over the past several months, I’ve spoken with several of the world’s leading cardiologists and lipidologists to better understand the key elements of heart disease prevention. One lipidologist I spoke with who works for a high-end concierge medicine service has had zero patients die of heart disease in the past ten years. What he does is not rocket science and anyone can do it if they know the right questions to ask. I’ve been compiling notes to get to the lowest common denominator of what is good enough and affordable so I can arm friends and family with the information and steps to put their heart health in their own hands. The best doctors unanimously agree that this is a preventable disease, but patients just don’t know what to do or how to navigate the health system to make sure they don’t succumb to it. This begs the question, if it’s so preventable, why don’t doctors take care of this for you?
This section is just me on a soapbox with an axe to grind about the way our healthcare system works. Feel free to skip it.
People who enter the medical profession usually do so for noble reasons. They want to help other people. It is extremely rewarding to save lives, and also emotionally turbulent when you can’t. Growing up, I watched my parents go to the hospital at all hours of the night when they were on-call. Their pagers would buzz and they’d drive right in. It’s a physically exhausting vocation, too. Doctors do not get enough credit for what they go through, both in terms of the time they spend training and the money they spend on medical school.
That said, as noble as the profession is, the incentives of our healthcare system are royally messed up. I am a firm believer that incentives drive behaviors. You can pretty much learn everything you need to know about why an industry works a certain way based on the underlying economic incentives. As a result, our healthcare system in the US is actually sick-care. It’s designed to treat sickness. That’s how it makes money. The sicker we are and the longer we are sick, the better it is for healthcare systems: from hospitals to big pharma to primary care doctors and all of these different constituents’ employees. The system doesn’t make money unless we are sick. (I highly recommend reading the book An American Sickness if you are interested in learning more about this.)
Once you understand that, it becomes obvious why we receive the type of medical care we do. Very few people in the medical profession are focused on ensuring we do not get sick. This work is largely relegated to preventative care doctors. Most of their services are out-of-pocket expenses since insurance really only covers things that treat sickness, not things that prevent it. That fact in and of itself is absolutely nuts. You’d think that insurance companies would want to pay to prevent you from getting sick because paying to treat you when you get sick is exponentially more expensive. But since your insurance is normally covered by your employer, and since the average American only stays with their employer for 3-4 years, there is no incentive to keep you from getting really sick since it likely will happen when you’re employed by someone else and under their insurance plan and dime. That is something uniquely American and a severe dysfunction of the system. Nobody wants to foot the bill for someone else’s problem down the road.
Anyways, back to these high-end concierge doctors that focus on preventative care. Since you’re paying out of pocket for them, they’re usually pretty darn good. They know a lot and are willing to do things that are outside of the standard healthcare guidelines. That’s because our guidelines usually lag 10-20 years behind the current science, and these preventative doctors follow the current science or something closer to it. The best practices they engage in are not common knowledge amongst most primary care physicians who are focused on cramming in as many patients in a day (every minute they run over with you is a dollar lost spending time with someone else). A lot of what concierge doctors do is bespoke and somewhat sophisticated and specific to their practices. But surprisingly, what they do to prevent and treat heart disease is not.
After speaking with many different practitioners who work in and run these practices, I’ve come to learn that everyone can get the same type of preventative heart healthcare that billionaires receive for roughly $300 or less a year. In fact, one person I spoke with who runs a very high-end concierge practice said to me that the heart health protocol of concierge medicine is something that really anyone can participate in so long as they know how to navigate it. That’s been the thing that’s shocked me the most - the fact that all of us can have access to the same heart healthcare that billionaires have access to for a couple hundred dollars out of pocket.
There are several different conditions that are categorized as heart disease, but for the sake of simplicity, I am going to talk about the most common one: atherosclerotic cardiovascular disease (which I will henceforth refer to as ASCVD). ASCVD is what happens when cholesterol-laden plaque accumulates in the arteries and begins to obstruct blood flow to the heart and other parts of the body. Heart attacks happen when this plaque breaks free of the artery walls and clogs your artery pathway (called the lumens), creating a blood clot that restricts blood flow. This often results in death. This is also what causes a stroke, but instead of blood not being able to circulate to the heart, it cannot circulate to the brain.
ASCVD is bad because the accumulation of plaque in your arteries is the thing that leads to a heart attack, and that’s the thing that can lead to death.
So how does plaque form? The short answer is that something called LDL penetrates your artery walls and begins to accumulate there and gradually turns into plaque.
The medium scientific answer (which I’ve mostly summarized from the work of Peter Attia and Thomas Dayspring) is:
Plaque forms in your arteries when a lipoprotein (a particle made of protein and fats that carries cholesterol and triglycerides through your bloodstream to your cells) called ApoB (short for apolipoprotein B, a lipoprotein that coats LDL) crosses the endothelium and gets stuck in the subendothelial space after it becomes oxidized there. There are several things that enable ApoB to make this journey, like smoking and high blood pressure which damage the endothelium and make it vulnerable to penetration. When ApoB accumulates in the subendothelium the immune system tries to attack them and it sends monocytes that turn into macrophages to eat this oxidized LDL in order to remove it from the artery walls. If the macrophages eat too much of it they explode into foam cells and when enough foam cells gather they form a fatty streak in the coronary artery. That is plaque! What’s crazy is this process begins when you are a teenager and compounds over the duration of your life. For some it moves fast, for others it moves slowly.
These foam cells continue to ooze together and form a mass of lipids. To control the damage smooth muscle cells in your artery migrate to this site and they secrete a kind of matrix in an attempt to build a barrier around it, just like a scar, that ends up as a fibrous cap atop arterial plaque. This plaque continues to grow, at first towards the outer arterial wall, but then into the lumen, the passage through which the blood flows. At a certain point in time this plaque hardens and becomes calcified. Once it’s calcified it mostly becomes a permanent fixture within your artery. Since it’s calcified it doesn’t go anywhere. While it may seem scary, calcified plaque is not the plaque that breaks free and causes a blood clot leading to a heart attack. It’s the non-calcified plaque - or soft plaque, the stuff that over time becomes calcified - that we need to worry about. Soft plaque can erode and rupture and create a heart attack via blood clot.
I also like Jeffrey Wessler’s simple explanation of heart disease: “Coronary artery disease occurs when circulating fats in the blood (e.g. LDL) are pushed by a driving force (i.e. blood pressure) into a vessel wall that is vulnerable.”
There are several things called risk factors that increase the likelihood of developing heart disease (ie these are conditions that make it more likely bad things happen). Examples include things like high blood pressure (which, as Jeff alluded to, is the driving force pushing that LDL into your artery walls), high blood cholesterol (if you have more LDL in your blood, then it increases the likelihood it can penetrate your artery walls), and smoking (which damages and inflames your artery walls, making it easier for that LDL to enter). Over 50% of people in the United States have at least one of these risk factors. There are other medical conditions and lifestyle choices that are risk factors, too, like diabetes, obesity, poor nutrition, being physically inactive, and drinking alcohol - pretty much the run-of-the-mill things that we’ve all heard about that are considered unhealthy.
My father’s friend, James Min, an entrepreneur and guru of mine who started Cleerly, explains heart disease as something that is multi-parametric. It’s a fancy way to say there are multiple different components as driving factors. He classified them as the following:
- Thrombotic - how well does your blood flow through your body?
- Inflammatory - what is the state of your arteries and general cardiovascular system? Are they functional and healthy? Do they suffer from inflammation?
- Atherosclerotic - what’s going on with your cholesterol?
- Metabolic - how well does your body turn food into energy? Are you diabetic?
All of these things meaningfully contribute to heart disease if they’re on the wrong side of the spectrum.
There are also some genetic things that determine how susceptible you are to heart disease. Genes like APOE, CETP and APOC3 all influence your risk of heart disease, and a bad lipoprotein called Lp(a) is also passed down hereditarily. It can be good to screen for these things so you know how at-risk you are and how seriously you need to take the matter.
ASCVD happens when plaque builds in your arteries, and it’s caused by arterial wall cholesterol build up which is influenced by a variety of other issues. But the good news is that those things are largely within our control. If we can focus on them, we can ultimately avoid dying of the world’s #1 killer.
There’s a term in medicine called preventative care. It’s a fancy way of saying, “Don’t get sick or diseased.” Preventing heart disease is important for a variety of reasons, the primary one being so you don’t die. There are some other benefits as well. The heart sits at the epicenter of all things longevity and healthspan. The things you do to protect your heart also carry over and help to stave off other deadly diseases like cancer, Alzheimers, and metabolic conditions. If you’re interested in living a long and healthy life, the heart is the best place to start.
Doctors talk about heart disease prevention in different stages. First, there is primordial prevention, which is preventing heart disease before you have any sign of atherosclerosis (plaque accumulation). This is the best time to start! After that is primary (defined as having identifiable risk factors but no plaque), secondary (having plaque seen on an imaging test but not yet having experienced a major adverse cardiovascular event) and tertiary (you’ve survived a majorly bad event). The second best time to start is primary, then secondary, then tertiary. This is because you really just want to avoid getting plaque in your arteries - that’s the stuff that causes heart attacks and stroke (ie death). Here’s an image one of the leading lipidologists, Thomas Dayspring, shared with me.
I’m at the secondary prevention stage. I have a little bit of plaque in my arteries as seen on my CTA scan, so I take this stuff seriously. I don’t want anymore to accumulate over time. If I can achieve that by managing my risk factors, taking some medications, and living a healthy lifestyle, I’ll be totally fine. These healthy habits will likely help me avoid succumbing to other bad diseases, too. That begs the question, how do we prevent this thing so we don’t die from it?
The Current State of Affairs
If you speak with any good cardiologist, lipidologist, or concierge doctor who knows about heart health, they will emphatically claim that what most primary care physicians will do with patients to help them avoid heart disease is not enough. The status quo simply does not work. If you go for your annual physical, they will likely draw some blood for a standard lipid panel where they look at your total cholesterol, LDL, HDL, and triglycerides, and maybe some other stuff. They will also use antiquated scoring methodologies like the Framingham Score to determine what your 10 year risk of having a heart attack is. They’ll also check your blood pressure. It’s definitely better than nothing, but it’s not good enough.
Primary care physicians are following standard guidelines. The problem is the guidelines that most doctors follow lag progress in science and knowledge by 10 to 20 years! That’s nuts! But that’s how long it takes to update these guidelines. The standard of healthcare you get is decades behind what it should and could be. Remember, the system behaves in a way that does not prevent you from getting sick or diseased. Fortunately, there’s a better way for you as a patient.
What To Do
Since I started my heart health journey, I’ve spoken with several of the world’s leading cardiologists and lipidologists to better understand the key elements of heart disease prevention. I’ve been lucky to access these people who mainly talk to me because they like my father. I’ve been compiling notes to get to the lowest common denominator of what is good enough (definitely not perfect!) and affordable so I can arm friends and family with the information and steps to put their heart health in their own hands. Fortunately, I’ve found that the steps and protocols for avoiding death by heart disease are very simple.
There are two things that are most important that your physician most likely will not do that you need to ask for to understand your risk factors and whether you currently suffer from heart disease. The results of these tests then determine the appropriate course of action for you (which will generally look similar for most people unless you are really diseased, in which case I’m glad you caught it now before dropping dead). These two things are called biomarkers and imaging diagnostics.
Biomarkers
Biomarkers are measurements of specific things in your body, mainly lipids and proteins, that are proxies for how susceptible you are to developing heart disease. Biomarkers that are abnormal (ie too high or too low) may mean that something is wrong. They are indications as to whether your risk factors are actually showing up in the chemistry and biology of your body.
I asked several leading lipidologists to stack rank what they believe are the most important biomarkers for people to measure and manage. There’s no consensus, but this is close to it. All of these can be accessed through bloodwork and urinalysis and can be done at a local Quest Labs (I’d venture to bet there’s one within a 10-mile radius of your home), prescribed by your doctor, and will likely cost anywhere between $80-$120 out of pocket.
- ApoB
- Lipid profile to know triglycerides
- One time Lp(a)
- hsCRP
- Microalbumin creatinine ratio (MACR)
- Uric acid
- Homocysteine
- Insulin level, glucose and A1C
- Omega 3 test (Omega 3 index or Omegacheck)
The only thing you’d normally get from a physician as part of an annual physical bloodwork would be the lipid profile. And within that, really what you want to understand is Triglycerides and LDL-C as the most important components. Most of the above can be found in an expanded lipid panel, ideally from the Cleveland Heartlab (owned by Quest), Labcorp, or Boston Heart.
Every lipidologist I’ve spoken with has stressed the importance of measuring and managing ApoB above all else – it’s a far better predictor of cardiovascular disease than LDL-C (which is what physicians are most familiar with). Every standard deviation increase of ApoB raises the risk of myocardial infarction by 38%. Yet because guidelines regularly lag science, the AHA still recommends LDL-C over ApoB. Test for it regularly (ideally twice a year) and work to get it as low as possible (longevity doctor Peter Attia recommends 30-40mg per deciliter). Many lipidologists will say to focus on this above all else.
If you want to know more about each of these biomarkers and why they are important, you can dig in further:
Biomarker | Indicator for | What is it? | What Test Covers it? | Don’t Die Ranges | How to address it |
ApoB | ASCVD | Measures the ApoB (carrier for LDL and other cholesterol) in your blood. Cholesterol carried in ApoB particles builds up in arterial walls, starting the narrowing and hardening process; most similar to ‘non-HDL’ measurement on standard lipid panel. | Expanded Lipid Panel | <60 mg/dL | Diet, statins, PCSK9 inhibitors, bempedoic acid, ezetimibe |
Triglycerides | Metabolic | Measures fats circulating in your blood stream. | Expanded Lipid Panel | <150 mg/dL | Diet and Exercise Fibrates, Statin, Fish Oil |
Lp(a) | ASCVD | Member of the ApoB particle family. Occurs when an LDL merges with an ApoA, and tends to capture other lipid molecules | Expanded Lipid Panel | <30 mg/dL | PCSK9 inhibitors, muvalaplin |
hsCRP | Inflammation | C-reactive protein tends to spike in reaction to tissue injury or inflammation | Expanded Lipid Panel | <0.5 mg/L | Diet and Exercise, appropriate lipid modulating drugs |
MACR (Urine microalbumin to creatinine ratio) | Inflammation | Test for Microalbuminuria, which causes kidney disease but is also a morbidity factor for cardiovascular risk. Studies have shown increases in risk for hypertensive people / diabetics, but also one which just shows an overall correlation with CVD deaths for people without these factors | Urine | <30 mg/g | Diet and Exercise |
Uric acid | Inflammation /ASCVD | Product from metabolizing purine, found in alcohol and food like meat/seafood. Too much can cause endothelial damage, increase blood pressure, and some studies show a correlation with Afib | Blood (Add On) | <5 mg/dL | Dietary changes to lessen purine rich foods, medication |
Homocysteine | ASCVD | Excess homecysteine may damage the lining of arteries or cause blood clots | Blood test | <10 umol/L | Dietary Changes, specific B vitamins |
Insulin/Glucose/A1C | Metabolic | Measures insulin efficiency and glucose control, indicating diabetes risk, which is a major cardiovascular risk factor. Can also screw up lipid metabolism, causing high TG, low HDL-C, and abnormal LDL-C | Blood test | A1C <5.7%, Fasting glucose <100 mg/dL, Insulin within reference range | Healthy diet, regular exercise, possibly medications for glucose control. |
Omega 3 test (Omega 3 index or Omegacheck) | ASCVD | Omega-3 fatty acids help lower triglyceride levels, which are linked with arterial buildup. When used in high-dose, prescription strength form can reduce TG and reduce residual risk after LDL-C is controlled in high CV-risk patients. | Blood test | >8% | Increase intake of fish or omega-3 supplements, reduce intake of omega-6 fats |
Imaging Diagnostics
Lipidologists focus on understanding biomarkers and managing them as much as possible. Cardiologists care about understanding the state of disease and treating it. The only real way to understand whether you have heart disease is to know whether you have plaque in your arteries, and the best way to do that is to take a look at it with imaging technology. The same way people do colonoscopies to visually see if they have cancer, people use tools like a CT or CTA scan to visually see if there is any plaque (both soft and calcified) that has accumulated in your arteries.
Every cardiologist I’ve spoken with recommends getting your calcium score either through a basic CT scan (which costs roughly $150 out of pocket unless your doctor is savvy enough to navigate insurance) or a CTA scan, ideally one with Cleerly (or HeartFlow) imaging (these cost more – anywhere between $1-1.5k). Your calcium score will tell you how much calcified plaque you have in your arteries (i.e. atherosclerosis). Remember, everyone accumulates plaque as they age. You don’t want any more of it. Calcium scores measure calcified or “hard” plaque, the stuff soft plaque turns into. It’s a proxy for how much plaque you’re accumulating. CT scans will tell you this.
A CTA will measure both hard and soft plaque and the Cleerly scan will give you a 3D visualization of your arteries, tell you where the plaque exists, how much and what kind there is, and where your arteries are narrowing. If price is not an issue for you, absolutely get a CTA with Cleerly. At the bare minimum, get a CT scan. Depending on these diagnostic results, you’ll need to repeat this test once every 1-5 years, depending on the state of disease. The same way you get a colonoscopy at regular intervals to detect colon cancer and other disease, you should do this, too.
Most physicians will not be able to understand or read the results of your CT or CTA scan. You’ll likely need to visit a specialist, ideally a cardiologist, to do this. If you’re curious about what these look like, I had a CTA done with Cleerly and here are my results. Your results will tell you your state of disease. Sometimes you may have none. That’s great! Other times you may detect a severe stenosis (narrowing of the artery), in which case cardiologists may recommend some form of intervention. That may sound scary, but it’s less scary than waking up one morning and dying of a heart attack.
Key Takeaway: Get a CT or CTA scan, and if you can afford it go for the CTA with Cleerly.
Other Tests: There are some other things that are important to know as well. You must know your blood pressure. Fortunately, your primary care physician is more than capable of doing this. Genetic testing helps understand your predisposition to heart disease. GBinsights seems to be the one most concierge doctors are currently obsessed with. An electrocardiogram can also be a good test for detecting other major heart problems.
Now that we know the tests we need to run to better understand our biomarkers and state of disease, we need to know how to treat any existing disease and disease progression.
Treatment
Medication
Between medication and knowledge about how to prevent or mitigate heart disease, we have all the requisite tools at our disposal to beat the thing. We should focus on mitigating our risk factors, managing biomarkers, and treating any existing disease we may have. If we think about the multi-parametric approach to heart disease, we have effective medications to help us across the board. The holy trifecta for heart disease are statins, ACE inhibitors, and baby aspirin (In Europe there is a polypill that combines these three drugs and has had an extremely positive impact).
- Atherosclerotic: To help drive down our ApoB, we have statins which do miracles for lipid management. Some people believe that everyone should be on a statin so long as they don’t have adverse side effects. One thing to note is that statins can oftentimes be prescribed in doses that are too high. With drugs like rosuvastatin, at 5mg most people get 85% of the maximum reduction in ApoB reduction, so there’s really no need to go higher than 10mg. For those that have adverse reactions to statins, we now have substitutes like Nexlitol (which can be expensive). We also have new drugs like PCSK9 inhibitors such as Repatha, Praluent or Leqvio (an expensive injection) which do wonders for lipid management. I take a statin and Ezetimibe which has absolutely crushed my ApoB levels (I am likely what is called a hyperabsorber). There are even new drugs that are having a remarkable impact on Lp(a), a biomarker that we struggled to move with therapeutics for ages.
- Thrombotic: ACE inhibitors will help to manage blood pressure if you have high blood pressure (another thing your PCP will test for). Baby aspirin will help with blood thinning and help to reduce blood clots - it has antiplatelet properties and can reduce arterial thrombosis.
- Inflammatory: To help manage inflammation, there are new medications like colchicine that are normally only used in very high-risk patients.
- Metabolic: We are entering an age of “magic medication.” With the advent of semaglutides (eg Ozempic, Wegovy, etc.), we now have medications that help with metabolic syndrome and weight management, and we have seen remarkable reductions in adverse heart events amongst populations on these medications.
If we go back to one of my favorite quotes, you’ll notice we have the right medications to treat the things that treat heart disease: “Coronary artery disease occurs when circulating fats in the blood (lipids) are pushed by a driving force (blood pressure) into a vessel wall that is vulnerable (endothelial dysfunction).” Ask your doctor or cardiologist about all of these and whether they’re right for you.
Behavioral
We can’t medicate heart disease out of existence quite yet. Behavioral changes, meaning modifying how you live your life, are usually also required. These changes are oriented around mitigating those risk factors we talked about: high blood pressure, high blood cholesterol, smoking, diabetes, obesity, poor nutrition, being physically inactive, and drinking alcohol. None of this should surprise you - it’s essentially being healthy. Fortunately, everything I’ve learned that is “most important” to do behaviorally has many positive externalities - not only will it help your heart health, but it will also help your overall healthspan.
This means regular exercise (both strength training, ideally 3x per week, and cardio training that helps to improve V02 max like Zone 2 training). It also means diet (nutrition, in addition to pharmacology, is the most important thing to reduce ApoB). Sticking to a Mediterranean diet that is light on carbohydrates and saturated fats is almost always the safest bet. Almost every health diet is some permutation of this. Also, if you smoke, stop immediately.
- You need to be mindful of what you put into your body. There are so many fad diets out there, but when it comes to heart health, it’s safe to say that a Mediterranean diet is best, ideally one that is focused on low carbohydrate and saturated fat intake. Don’t eat too much. Don’t eat too little. For me, as simple as this guidance is, I’ve found it to be the most difficult part. I love food. Particularly the stuff that’s not good for you: pasta and pizza and bread. I don’t beat myself up over being perfect when I diet. I just try to focus on eating well during the week, and on the weekends, I’ll usually indulge a couple times. What’s more important to me is the quality of the food I eat - I really try to avoid processed foods and stick to whole foods.
- Regular exercise is critical, but being deliberate about the type of exercise is super important. We should target strength training ideally three times per week with a focus on resistance training. For cardio work, we should focus on improving our VO2 max by trying to get 2-3 hours of Zone 2 training in per week, and a set of HIIT at Zone 4. That’s a lot of stuff. Realistically, it’s nearly impossible to do that every week if you have a job, children, responsibilities, etc. I try to focus on the resistance training and Zone 2 training and get in 5-6 workouts per week. I don’t stress when I’m not perfect about this.
- You need to sleep. Ideally, somewhere between 7-9 hours per night. Without it, we die faster. End of story. I used to invest in sleep trackers and neat technology to help me sleep better, but I found that being overly scientific about it made me sleep worse. I was putting pressure on myself to sleep better, and that pressure made me sleep worse. I usually know how much sleep I get, and I don’t really care about what “kind” of sleep I get so long as I feel good in the morning.
- Stress sucks, and it kills you. And throwing your emotional health to the wayside can make life feel not fun. There’s enough literature out there with regard to how to manage stress and stay in touch with your emotions. I won’t get into it. I have been talking to a therapist weekly for years. It’s helped me to understand how to label my emotions, how those emotions drive my behaviors, and what causes me to feel those things. That’s been super helpful. I also love the mindfulness app Waking Up by Sam Harris. I think it’s like meditation, but it really works for me.
- If you smoke, don’t. It’s going to kill you. You know that. It is the easiest way to die of heart disease. I used to smoke cigarettes. I picked them up in high school, smoked throughout college, and intermittently did when I was building my first two companies. I know how hard it is to quit. I’ve successfully used nicotine mints and gum over the years to wean myself off cigarettes.
- Alcohol isn’t good for your health, and it’s really bad for your heart health. I think it’s unreasonable to tell people not to drink alcohol if they like it. I like an occasional glass of wine, and I love tequila. And I also like to drink in some social settings, but I don’t drink very often. As I’ve gotten older, my body just can’t handle it. It makes me sleep like crap, and I always feel bad the next morning. If you’re going to drink, at least make sure it’s really good alcohol that you enjoy and don’t drink too much of it.
These are a lot of behavioral changes! It can seem daunting. It is daunting. It’s hard to stomach just how to do all this stuff at once. Over time I think I’ve worked on it enough and it now brings me joy to exercise, eat well, and get sleep. I feel unhealthy if I don’t do those things, so they are just part of my routine. I’m no expert at habit forming. I’ve read some books on it, but generally, what I’ve found works for me is just biting off a little bit at a time and not getting mad at myself for not doing this perfectly. Everyone has their own healthy balance of enjoying life and its indulgences and being healthy. Find yours. It’s a lifelong journey.
(PS - for those who are interested in supplements, I recommend following SuppCo’s Heart Health Supplement Stack)
Between medication and knowledge about how to prevent or mitigate heart disease, we have all the requisite tools at our disposal to beat the thing. Every single lipidologist and cardiologist I’ve spoken with unanimously agrees that for almost everyone (unless you are an edge case or severely meaningfully diseased already) what I’ve highlighted above will do the trick. It’s not perfect by any means, but if people just did this stuff, heart disease would no longer be the leading cause of death.
These tests and medications and knowledge about healthy behavior have existed for a long time. They’re tools that are readily available and at our disposal, but you have to ask for them. They are not prescribed unless you are sick. And unfortunately, when it comes to heart disease, being sick sometimes means being dead. It takes effort to prevent this. Like many things, the biggest hurdles are knowledge and willpower. My hope is that the knowledge becomes pervasive, that accessing these diagnostics and treatments becomes easy, cheap, and ubiquitous (they pretty much already are), and that people are motivated enough to be their own advocates and take their health into their own hands and make the conscious decision to not die of heart disease.
You can die of something else, just not heart disease.
You have probably noticed this in the past, but if there’s one thing most physicians hate, it’s when their patients show up with a list of questions and demands because they “read something on the internet.” The “WebMD Patient” is oftentimes a loathed one.
I’ve gotten pretty good at this over time. Every time I visit the doctor or take my children to the doctor or have ended up in the hospital, I’m asked what type of medicine I practice. Both of my parents were doctors, so I was sort of raised with all this stuff floating around the house, but it doesn’t take much to have a physician begin to take you seriously. Normally, the biggest source of annoyance is they don’t want to spend unnecessary time with you because their incentive is to just see as many patients as they possibly can within one day.
So you’re going to show up to your doctor, either in person or via telemedicine, and begin to ask for a bunch of stuff that they don’t do for other patients and that will likely be new to them. They may not even know what much of the stuff you’re going to ask for is or means. It’s a recipe for chaos! But whatever. It’s your health. You’re your own Advocate. You have every right to ask for this stuff. I wrote a script for you to make your life easy. You can recite this aloud, print it out and bring it in, or just email it to them:
Hi Doc,
I’ve made the decision to take my heart health into my own hands, and I don’t want to die of heart disease. I need you to please order me some tests that are necessary for me, and I’ve made the decision that I want them. Here’s what I need:
- I need an expanded lipid panel so I can understand the following biomarkers. You can order this from Cleveland Heart Labs, which is part of Quest Labs. I’ll also need a urinalysis to test for some of these biomarkers. I realize there will be an out-of-pocket expense, but it should not be any more than $100. Here’s what I need to test for:
- ApoB
- Lipid profile to know triglycerides
- Lp(a)
- hsCRP
- MACR
- Uric acid
- Homocysteine
- Insulin level and of course glucose and A1C
- Omega 3 test (Omega 3 index or Omegacheck)
- I also need to do a CT Scan because I need to know my calcium score. I know this will be another out-of-pocket expense, but it shouldn’t cost me more than $150.
- If you are willing to spend more and get a better test result, replace CT Scan with CTA scan and $150 with $1,000. Ask to do a CTA with a Cleerly or HeartFlow reading.
- While I’m at Quest or even right now, let’s check my blood pressure to ensure everything is okay.
When I get the results from these tests, I’d love to review them with you. If you don’t feel comfortable reviewing them with me, I’m happy to work with another doctor or cardiologist within my network that you’d recommend. I will also dump them into ChatGPT and see what it recommends and you can tell me whether you agree or disagree.
Thank you for helping me not die of heart disease! I really appreciate your supporting my decision to learn more about my heart health and to live a long and healthy life.
It’s pretty straightforward. If your doctor pushes back on you, just repeat: “I’ve decided to not die of heart disease and these are the tests I need to feel comfortable and address my own body and health. If you can’t order me these tests, please let me know and I am happy to take my business elsewhere.” And if they try to push and prod you on why you want every one of these tests, you can point them here.
What should you do with your test results?
Throw them into ChatGPT, of course! (And share them with your doctor.)
Here are some of my latest labs that I’ve done. And below is what ChatGPT says in response to these questions:
- I am a 37-year-old male. I am 5’10 and weigh 170 pounds. I currently take a statin and ezetimibe.
- Does anything stand out to you? Is anything abnormal?
- Are there any biomarkers I should focus on improving?
- What should I do to improve or maintain these results?
Here’s the response:
“Based on the lab results you've shared, several markers are notable and some recommendations can be made. Let's break it down:
Key Findings
- LDL Cholesterol (LDL-C): Your LDL-C is at 29 mg/dL, which is considerably below the optimal range. This is very low, likely due to your statin and ezetimibe therapy. While low LDL-C reduces cardiovascular risk, extremely low levels should be discussed with your doctor to ensure they are safe and intended.
- HDL Cholesterol (HDL-C): Your HDL-C is 44 mg/dL, which is acceptable but on the lower side of optimal (optimal is usually above 50 mg/dL). Higher HDL-C is generally protective against heart disease.
- Triglycerides: Your triglyceride level is 74 mg/dL, which is well within the optimal range.
- Lipoprotein (a) [Lp(a)]: Less than 10 mg/dL, which is excellent as high levels are associated with increased cardiovascular risk.
- Inflammation (hs-CRP): Your high-sensitivity C-reactive protein is <0.2 mg/L, indicating very low levels of inflammation, which is good for cardiovascular health.
- Omega-3 Index: Your omega-3 fatty acid levels are healthy at 6.8%, with a good balance between EPA and DHA, which are important for heart health.
Recommendations
- Discuss LDL-C Levels: Given your very low LDL-C, it would be worthwhile to discuss with your healthcare provider whether adjustments to your statin therapy might be appropriate, or if such low levels are part of a therapeutic strategy, especially if you have a history of cardiovascular disease.
- Boost HDL-C: To potentially improve your HDL-C, consider increasing physical activity, possibly incorporating more aerobic exercises. Additionally, dietary adjustments such as including more healthy fats from nuts, olive oil, and fatty fish can help.
- Maintain Healthy Lifestyle: Continue with a balanced diet rich in fruits, vegetables, whole grains, and lean proteins. Limit intake of saturated fats and sugars, which you seem to be managing well given your current lipid profile.
- Monitor and Maintain: Regular monitoring of your cholesterol levels and other biomarkers, along with routine consultations with your healthcare provider, will be essential in maintaining your health status, especially considering your current medication regimen.
Your current lab results suggest effective management of cholesterol and cardiovascular risk factors, likely aided by your medication and possibly your lifestyle choices. However, always consult with your healthcare provider for personalized advice and to ensure that your treatment plan is optimal for your specific health needs.”
Pretty incredible. Also free.
I can share this and the results directly with my doctor and make life easy.
I will try to update this over time. Ideally, I’d just like to open this up to a handful of people who care about it and we can all update it together.
I hope you find this useful. I hope you get a CTA or CT scan. I hope you learn about your biomarkers and risk factors. I hope you share this with your friends and loved ones. I hope you help yourself and others not die of heart disease.
If you’re interested in staying updated about heart-related things, drop your email here and I’ll send out a note whenever I get around to updating this.
Good luck. You got this.
I want to thank a lot of people who helped me along my heart health journey: Harvey Hecht, James Min, Thomas Dayspring, Arthur Agatstan, Andrea Klemes, Louis Malinow, Jeffrey Wessler, Neil Parikh, Steve Martocci, Alan Tisch, David Kopp and Carrie Weprin.