<p><span style="color: #000000;">Allan Sniderman is a highly acclaimed Professor of Cardiology and Medicine at McGill University and a foremost expert in cardiovascular disease (CVD). In this episode, Allan explains the many risk factors used to predict atherosclerosis, including triglycerides, cholesterol, and lipoproteins, and he makes the case for apoB as a superior metric that is currently being underutilized. Allan expresses his frustration with the current scientific climate and its emphasis on consensus and unanimity over encouraging multiple viewpoints, thus holding back the advancement of metrics like apoB for assessing CVD risk, treatment, and prevention strategies. Finally, Allan illuminates his research that led to his 30-year causal model of risk and explains the potentially life-saving advantages of early intervention for the prevention of future disease.</span><span style="color: #333333;"><br /> <br /></span><span style="color: #000000;">We discuss:</span><span style="color: #333333;"><br /></span></p> <ul> <li><span style="color: #000000;">Problems with the current 10-year risk assessment of cardiovascular disease (CVD) and the implications for prevention [4:30];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">A primer on cholesterol, apoB, and plasma lipoproteins [16:30];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Pathophysiology of CVD and the impact of particle cholesterol concentration vs. number of particles [23:45];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Limitations of standard blood panels [29:00];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Remnant type III hyperlipoproteinemia—high cholesterol, low Apo B, high triglyceride [32:15];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Using apoB to estimate risk of CVD [37:30];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">How Mendelian randomization is bolstering the case for ApoB as the superior metric for risk prediction [40:45];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Hypertension and CVD risk [49:15];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Factors influencing the decision to begin preventative intervention for CVD [58:30];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Using the coronary artery calcium (CAC) score as a predictive tool [1:03:15];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">The challenge of motivating individuals to take early interventions [1:12:30];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">How medical advancement is hindered by the lack of critical thinking once a "consensus" is reached [1:15:15];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">PSK9 inhibitors and familial hypercholesterolemia: two examples of complex topics with differing interpretations of the science [1:20:45];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Defining risk and uncertainty in the guidelines [1:26:00];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Making clinical decisions in the face of uncertainty [1:31:00];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">How the emphasis on consensus and unanimity has become a crucial weakness for science and medicine [1:35:45];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Factors holding back the advancement of apoB for assessing CVD risk, treatment, and prevention strategies [1:41:45];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">Advantages of a 30-year risk assessment and early intervention [1:50:30];</span><span style="color: #333333;"><br /></span></li> <li><span style="color: #000000;">More.</span></li> </ul> <div>Learn more: <a href="https://peterattiamd.com/">https://peterattiamd.com/</a><br /> Show notes page for this episode: <a href="https://peterattiamd.com/AllanSniderman">https://peterattiamd.com/AllanSniderman</a> <br /> Subscribe to receive exclusive subscriber-only content: <a href="https://peterattiamd.com/subscribe/">https://peterattiamd.com/subscribe/</a><br /> Sign up to receive Peter's email newsletter: <a href="https://peterattiamd.com/newsletter/">https://peterattiamd.com/newsletter/</a><br /> Connect with Peter on Facebook | Twitter | Instagram.</div>
Actionable Insights
1. Measure ApoB for Atherosclerosis Risk
Measure ApoB levels as it is a superior metric for predicting atherosclerosis risk compared to LDL cholesterol and non-HDL cholesterol, providing a more accurate count of atherogenic particles.
2. Target ApoB in Lipid-Lowering Therapy
Use ApoB as the primary target for lipid-lowering therapy, as its reduction directly correlates with fewer atherogenic particles entering the arterial wall, which is the fundamental cause of atherosclerosis.
3. Assess Long-Term Cardiovascular Risk
Evaluate cardiovascular risk over a 20-30 year horizon, especially for individuals in their 30s and 40s, to make prevention decisions more meaningful and capture premature disease risk that 10-year models miss.
4. Intervene Early for High-Risk Individuals
Identify and consider early intervention for the approximately 20% of the population at evident high risk (e.g., high ApoB levels) to prevent disease development rather than just modifying existing disease later in life.
5. Measure LP(a) for Enhanced Risk Assessment
Measure LP(a) (lipoprotein(a)) once for additional risk assessment, particularly when combined with high ApoB, as it can indicate a ‘double whammy’ of increased atherogenic risk.
6. Diagnose Type 3 Dyslipoproteinemia with ApoB
Measure ApoB along with total cholesterol and triglycerides to diagnose Type 3 dyslipoproteinemia, a highly atherogenic condition that cannot be identified without ApoB measurement.
7. Treat Type 3 Dyslipoproteinemia Effectively
Treat Type 3 dyslipoproteinemia, once diagnosed, with statins and/or fibrates, as patients typically respond very well to these therapies.
8. Utilize the ApoB App for Diagnosis
Use the ApoB app (www.apoBapp) by plugging in total cholesterol, triglycerides, and ApoB values to aid in the diagnosis of atherogenic ApoB dyslipoproteinemias.
9. Consider CAC for Young, Undecided Patients
Consider a Coronary Artery Calcium (CAC) score for younger patients (under 60) who are on the cusp of treatment decisions or need more information, as a positive score can be extremely helpful in motivating intervention.
10. Don’t Delay Treatment on Negative CAC
Do not use a negative Coronary Artery Calcium (CAC) score to delay treatment decisions for individuals with high ApoB or other vascular disease causes, as calcification is a feature of advanced disease and its absence doesn’t rule out developing atherosclerosis.
11. Monitor Therapy with ApoB Levels
Monitor the effectiveness and adherence to lipid-lowering therapy by tracking ApoB levels, as a significant reduction indicates the medication is working to lower atherogenic particles.
12. Understand Atherosclerosis Natural History
Gain a deep understanding of the natural history of atherosclerosis, recognizing that the disease begins in the first three decades of life, to construct effective long-term prevention strategies.
13. Be Aware of Statin Risks
Be aware that while statin therapy is highly effective, it is not without cost, and the full relationship between statins and conditions like diabetes is not yet completely understood.
14. Access In-Depth Health Content
Consider joining a membership program, such as the one offered by The Drive podcast, to access more in-depth and exclusive content to elevate your knowledge in health and wellness.