The Peter Attia Drive - #203 - AMA #34: What Causes Heart Disease?

Episode Date: April 18, 2022

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter In this “Ask Me Anything” (AMA) episode, Peter dives deep into the topic of atherosclerotic cardiovascular disease (ASCVD)—the number one killer in the developed world. Peter argues for the importance of paying attention to and understanding ASCVD given its ubiquity and inevitability. He goes into great detail about the development of atherosclerosis and how it can take hold at a very early age, the role of cholesterol, and the causal factors of ASCVD that determine prevention strategies. Additionally, he discusses the important metrics and biomarkers found in blood work, as well as diagnostic tests such as coronary artery calcium scores (CAC) and CT angiograms which help to determine the level of arterial damage present. Finally, Peter lays out the keys to understanding and interpreting calcium scores before wrapping up the conversation with his key takeaways regarding prevention. If you’re not a subscriber and listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #34 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: The importance of understanding atherosclerosis early in life [2:15]; Defining atherosclerotic cardiovascular disease (ASCVD), its causes, and the role of cholesterol [9:00]; The process of developing ASCVD, part 1 [15:00];  The process of developing ASCVD, part 2 [24:00]; The process of developing ASCVD, part 3 [32:45]; How early in life ASCVD can start to develop [40:30]; Case studies of atherosclerosis and figures showing real pathology [43:00]; Coronary artery lesions present in autopsies of different age groups [49:15]; The causal factors of ASCVD that determine prevention strategies [52:15]; Labs to identify biomarkers of ASCVD ]59:00]; Diagnostic tests to determine the level of arterial damage present—CAC, CTA, CIMT, and more [1:00:30] Keys to understanding and interpreting a CAC score and/or CTA results [1:05:15]; Is there a risk from cholesterol levels being too low? [1:13:00]; Key takeaways regarding prevention [1:15:45]; More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

Hey everyone, welcome to a sneak peek, ask me anything, or AMA episode of the Drive Podcast. I'm your host, Peter Atia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to PeterittiaMD.com forward slash subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything episode number 34. I'm once again joined by Nick Stenson. In today's episode, who do a super deep dive answering a lot of questions that have been accumulating

around atherosclerotic cardiovascular disease? Now, atherosclerosis, of course, is the number one killer in the developed world. It affects basically everybody. So you undoubtedly know somebody who's affected by this, if not you. So we thought it was really time to kind of focus deep on this. So for this reason, we combined a lot of previous questions

that have come in into this episode. And so we discuss a lot of things here. We discuss why everybody should care about atherosclerosis. We talk about exactly what it is and try to explain how it comes about. Now it's important to spend a lot of time on this because if you want to understand how to prevent it, you really need to understand how it's caused.

And then that'll give you some sense of what the markers are and what the markers don't tell you and what they do tell you. So we look at why it's not a disease that only affects old people, but why it really takes hold at an early age. And you need to be aware of this if, of course, you want to present it. We talk about cholesterol, blood work, what these numbers mean, what's typically run, what's not run, what metrics I like to look at and what you should be concerned over. We also get into a question that comes up a lot, which

is can cholesterol levels be too low? So if you're taking medication-staloric cholesterol, what happens if your cholesterol levels get really no? What are the risks of that? From there, we answer questions around coronary artery calcium scores or CACs, CIMT, CTN, Geogram, and a whole bunch of other things along that. So if you're a subscriber and you want to watch the full episode of this in video, you can do so on the show notes page, and of course we'll have the show notes that include a whole bunch of details. Worth pointing out here before I start, this is an episode where I probably have more figures than any other episode I've done.

So even if you're not someone who likes to look at the graphics, I think this is the one time you probably want to make an exception and watch the video. If you're not a subscriber, you can still the graphics, I think this is the one time you probably want to make an exception and watch the video. If you're not a subscriber, you can still catch a sneak peek of this on our YouTube page. So without further delay, hope you enjoy AMA number 34. I'm not too into that. How are you doing? I'm good. We got a doozy today.

More so than usual. I know. Embracing myself for the intensity of this discussion. We've accumulated, I don't know, almost an endless supply of questions on heart disease in one format or another, the specifics around lipids, atherosclerosis in general, these things like that. And so, as is often the case, I think we've accumulated a critical mass of questions that we can now organize them into a coherent and thoughtful discussion around all things related to arthroscoposis. So I know you've done an amazing job taking these questions and organizing them

in a way that makes for hopefully a logical discussion. So let's take it away. The hope is a lot of this stuff we're going to talk about today, we could dive in so deep. So many of these questions could be their own AMA, but what we thought as a team was, it'd be just much better to touch on all these aspects, so people who listen top to bottom can just get a really good understanding of what this is, why they should care about it, how they should think about it. On that note, what we thought would be important is just answering the first question, which is, why should someone care about this? It's such a complex topic. Why

is it important for people to put the time in to really think through and understand it? It really starts with the ubiquity of this disease, and it's assault on human longevity. People have probably heard me say this before, but atherosclerosis is really the only inevitable disease of our species. Cancer, while prevalent with aging and dementia, while prevalent with aging, do not appear inevitable the way atherosclerosis does. So not everybody dies from atherosclerosis, but I think to my knowledge, everybody dies with with it assuming they live long enough. So you have a condition that, as I said, is inevitable is ubiquitous. Also, I think based on what you're going to hear me talk about today,

we know a lot about this condition and we really have tools to mitigate it. To me, that's the reason you want to really understand this. The impact is huge and the tools that we have are also huge. So again, we talk about longevity. Longevity has two parts, health span, life span. The life span part comes down to delaying the onset of chronic disease, of which this is the most common chronic disease. So you can think of a couple of different paths to get there,

but really the two biggest risk factors, I am putting smoking aside for a moment, which is a very straightforward behavioral risk factor. In terms of less clear behavioral risk factors, the two biggest are clearly hypertension, high blood pressure, and lipid abnormalities. And that's the one we're gonna focus on here. So, atherosclerotic cardiovascular disease

will just abbreviate ASCVD for short is really what we're here to talk about. As we get started on this topic, Peter, I think we have people who listen to this podcast of all ages, young, old, everywhere in between. And I think it's a common thought for people under 30, 40, even some people under 50, where they're just like, this is something that only affects old people.

I'll think about this when I'm older, but right now it doesn't really affect me. How do you answer the question in its basic form of, isn't this just a disease of old age? And why should those people who think that not just shut off the podcast at this point and instead continue to listen and continue to put in the effort. Probably have told this story before and if not, where folks haven't heard it, I think it's worth hearing again right now. I remember in sort of my first year pathology lecture in medical school that pathologist

said, what's the most common presentation for a first heart attack? So if a person is having their first heart attack, what is the most common thing that they will present with? That's the terminology we use in medicine. And of course, the hands shot up, chest pain being the obvious. Nope, that's not it. Nausea, nope, that's not it. Oh, left arm pain. No, that's not it. And it was a trick question, of course. The answer was sudden death. The answer was that over 50% of people's first heart attack is fatal. Now the good news is today that number is a little bit less. It's probably slightly below 50%, but that's still a staggering number. Now another way to think about this is through the lens of

understanding the age distribution of people who have their first major adverse cardiac offense. So that is a heart attack stroke or sudden death due to one of those. If you don't mind, Nick, pull up figure one. This graph shows the age distribution for both male and female in the United States in terms of these incidents. I think the easiest graph for me to look at here is the one on the right, total annual events. And what you can focus on is the first two bars. That is the bars that are for people up to the age of 65. So if you look at the male bars,

which are the darker bars, you can see that the sum total of those two bars, slightly below 25%, slightly above 25%. The implication of that is over 50% of men who are going to have a cardiac event in their life will have it before the age of 65. And for women, you do the same exercise, you can see that it's one third of women. So it's clear that there's a shift in time and that women, while subject to the exact

same burden of disease, seem to experience it about a decade later. Still fully one third of women are going to have their first cardiac event, which is going to be heart attack, stroke, or death as a result of those things before the age of 65 and a little over 50% of men will be in that camp. So, as we're going to talk about in this episode, that's not the whole story. It's even more compelling to care about this when you're young, when you understand how long it takes for this disease to take hold, and the implications therefore for prevention. The most sobering thing for me when you look at this is it's not even the 50% under 65, it's almost the, especially for males, the almost 25% under 54. And especially when we get to what we get to later, which is for that to happen to someone

who's 45-50, it doesn't mean it started two years earlier. And so I think it's pretty crazy when you see these types of stats laid out, how it creates that shift in your mind around why you should care about this. I think what we need to do is first, almost step back and look at what exactly is ASCVD. I think people have to understand what it is to then really understand how it comes about, how to think about prevention. So, what do you think the best way to walk people through in a relatively simple form, what this disease is?

I'll explain it at a high level now, and I think we should go through it in some detail in a moment. The pre-C on this would be that ASCBDs, a disease state characterized by the deposition with a buildup of cholesterol, more clearly, or more rigorously sterols, which include cholesterol and phytostereol in the artery wall.

It initially starts as something called a fatty streak, which I'll explain in a little bit more detail later, and then it later consolidates into things called plaques, and these can ultimately lead to a reduction in blood flow. And of course, it's this reduction in blood flow that leads to what's called ischemia. Ischemia is the reduction in blood flow, and therefore the resulting tissue damage that occurs to the heart is what results in a heart attack, which can be fatal, depending on the amount of the cardiac tissue that is impeded from appropriate amount of oxygenation. To have this disease, you don't have to be obese, you don't have to have high blood pressure or things of that nature. It's really a question of the cholesterol in your blood. That's really what defines the disease. So the essential condition of atrosclerosis is the presence

of cholesterol in the artery wall, which by the way is not necessarily related to the measure of cholesterol in circulation, which we will talk about in great length. And although these often co-exist, patients with cholesterol in their arteries do not necessarily have to have co-aggravating factors, such as high blood pressure, diabetes, obesity, family history, smoking, all these things that exacerbate it. You mentioned cholesterol a few times, and obviously it's a topic that's been talked about on more podcasts than I can even counter recall right now. But for this conversation, can you define cholesterol

just in its simplest form? So everyone's aware of exactly what we're talking about as we're going to get into kind of the more nitty-gritty. Cholesterol is an organic molecule that resides in the lipid family. So we typically characterize these molecules by their solubility in water. And this is a not- not soluble in water molecule.

So it is a hydrophobic molecule. And I think the easiest way to sort of picture those things is to think about oils. So if you took an oil like olive oil and you poured some of it into a cup of water, you would immediately see what it means to have a hydrophobic substance in contact with something, which is the ultimate hydrophilic substance water, right? So they repel each other. Now, of course, cholesterol is about one of the most important molecules in the body. To be clear, if we didn't have the ability to make cholesterol, we would cease to exist. In fact, you couldn't be born without the ability to do this. There are rare genetic conditions that impair the ability to make cholesterol, and these are uniformly fatal. Why do we need cholesterol? There are broadly two things that cholesterol is essential for. The first is that they contribute

heavily to the cell membrane of virtually every cell in the body. So cells are actually kind of fluid things, spherical things, and what allows them to have that fluidity and what allows them to have membrane channels that allow things in and out of them is the cholesterol layer that forms the membrane. And secondly, cholesterol is an essential substrate for the production of some of the

most important hormones in the body, cortisol estrogen, testosterone. It's also essential for the creation of bile acids, which are necessary to be able to digest food. So the mantra that I like to say is no cholesterol, no life period. You should put that on a bumper sticker on your car, just roll around Texas with that guy. No, I think that's great. The next section we're going to go through, which has the potential to be a little deeper than a lot of what this conversation is, which is how this all comes about. And luckily, in a quick shout out to Tom Daye Spring, who created a bunch of images that

we're going to look at, this kind of allows us to dive into this. And so for people who are listening to this, if you can watch a video, it's probably going to be really helpful, but otherwise the show notes will also have all these images. But why don't we look at and discuss Peter, how does ASCVD come about? Thank you for listening to today's

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