#238 – AMA #43: Understanding apoB, LDL-C, Lp(a), and insulin as risk factors for cardiovascular disease

<a href="https://peterattiamd.com/ama43/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=230116-pod-ama43&utm_content=230116-pod-ama43-podfeed"> View the Show Notes Page for This Episode</a> <a href="https://peterattiamd.com/subscribe/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=230116-pod-ama43&utm_content=230116-pod-ama43-podfeed"> Become a Member to Receive Exclusive Content</a> <a href="https://peterattiamd.com/newsletter/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=230116-pod-ama43&utm_content=230116-pod-ama43-podfeed"> Sign Up to Receive Peter's Weekly Newsletter</a> In this "Ask Me Anything" (AMA) episode, Peter answers questions related to the leading cause of death in both men and women—atherosclerotic cardiovascular disease (ASCVD). He highlights the most important risk factors for ASCVD, such as apoB, LDL, hyperinsulinemia, and Lp(a), and explains the mechanism by which they confer risk and how these factors are interrelated. Peter also dives deep into the data around apoB to try to answer the question of how much residual risk is conferred for ASCVD through metabolic dysfunction once you correct for apoB. He also looks at the data around lifetime risk reduction of ASCVD in the context of low apoB. If you're not a subscriber and are 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 <a href="https://peterattiamd.com/members/private-podcast-feed/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=230116-pod-ama43&utm_content=230116-pod-ama43-podfeed">private RSS feed </a>or our website at the <a href="http://peterattiamd.com/ama43/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=230116-pod-ama43&utm_content=230116-pod-ama43-podfeed">AMA #42 show notes page</a>. If you are not a subscriber, you can learn more about the subscriber benefits <a href="https://peterattiamd.com/subscribe/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=230116-pod-ama43&utm_content=230116-pod-ama43-podfeed">here</a>. We discuss: <ul type="disc"> <li>A racecar analogy for understanding atherosclerotic cardiovascular disease [2:00];</li> <li>Defining and differentiating apoB and LDL-C [10:00];</li> <li>The interrelated nature of insulin levels, apoB, triglycerides, and ASCVD parameters [13:00];</li> <li>Another way that hyperinsulinemia plays a role in endothelial dysfunction [18:00];</li> <li>Why Peter uses the oral glucose tolerance test (OGTT) with all patients [20:15];</li> <li>Is there any evidence that hyperinsulinemia is an independent contributor to ASCVD? [23:00];</li> <li>Thinking through risk in the context of high-fat diets resulting in improved metabolic metrics but with an elevation of apoB/LDL-C [27:30];</li> <li>Thinking through risk in the context of low apoB but higher than normal triglyceride levels [32:15];</li> <li>The importance of lowering apoB for reducing ASCVD risk [38:15];</li> <li>Data on men and women with familial hypercholesterolemia that demonstrates the direct impact of high apoB and LDL-C on ASCVD risk [47:45];</li> <li>Importance of starting prevention early, calcium scores, and explaining causality [52:30];</li> <li>Defining Lp(a), its impact on ASCVD risk, and what you should know if you have high Lp(a) [56:30];</li> <li>Lp(a) and ethnic differences in risk [1:00:30];</li> <li>Why someone with elevated Lp(a) should consider being more aggressive with apoB lowering strategies [1:05:00];</li> <li>Addressing the common feeling of hesitancy to taking a pharmacologic approach to lower ASCVD risk [1:07:15];</li> <li>Peter's take on the 2022 Formula 1 season and thoughts on 2023 [1:15:15]; and</li> <li>More.</li> </ul> Connect With Peter on <a href="https://twitter.com/PeterAttiaMD">Twitter</a>, <a href="https://www.instagram.com/peterattiamd/">Instagram</a>, <a href="https://www.facebook.com/peterattiamd/">Facebook</a> and <a href="https://www.youtube.com/channel/UC8kGsMa0LygSX9nkBcBH1Sg">YouTube</a>

Actionable Insights

1. Prioritize Early Risk Intervention

Address atherosclerotic cardiovascular disease (ASCVD) risk factors like ApoB, hyperinsulinemia, smoking, and hypertension early in life, as prompt action allows for more effective interventions and slows disease progression.

2. Monitor ApoB Over LDL-C

Prioritize measuring and monitoring ApoB concentration over LDL-C for assessing ASCVD risk, as ApoB is a better predictor that captures all atherogenic particles and serves as a key goalpost for risk reduction.

3. Detect Hyperinsulinemia Early

Look for postprandial hyperinsulinemia, characterized by elevated insulin 30-60 minutes after a glucose challenge, as a “canary in the coal mine” for early insulin resistance and increased ASCVD risk, even if fasting glucose is normal.

4. Utilize Oral Glucose Tolerance Test

Consider undergoing an Oral Glucose Tolerance Test (OGTT) to assess your postprandial insulin levels, which can help detect early insulin resistance and provide insight into your current metabolic state, even if you don’t have type 2 diabetes.

5. Actively Manage ASCVD Drivers

Focus on actively lowering high blood pressure, ceasing smoking, and reducing ApoB levels, as these are identified as the three primary and most impactful drivers of atherosclerotic cardiovascular disease (ASCVD).

6. Understand Lp(a) Baseline Risk

Recognize that Lp(a) levels are largely genetically determined and not directly modifiable, serving as a “low level of maintenance throttle” that contributes to baseline ASCVD risk.

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