The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
03 Feb 2025
What is atherosclerotic cardiovascular disease (ASCVD)?
But two things, their protein content, over 150 proteins have been found to be associated with various HDL particles. And they perform an immense number of likely very necessary actions that need to go on in certain tissues where things may be going wrong. We also know that the coat of an HDL, apart from its proteins, is virtually all phospholipids.
So the exact phospholipid concentration of an HDL surface has tremendous amount to what to do. Can an HDL do wonderful things or bad things? Those phospholipids really determine what an HDL can bind to in various tissues. Now, of course, we can't measure HDL phospholipid content. There are hundreds of phospholipids.
You would get a lipidome coming back that you couldn't even pronounce half of the phospholipids or at least the fatty acids that are in those phospholipids. And same with the protein. If there's 150 of them, I guarantee the average doctor might be familiar with about 10 of those proteins and not with the rest of them. So I don't know how to determine a patient's HDL functionality.
Clearly, the people having adverse effects with high HDL cholesterol have dysfunctional HDLs probably related to that proteome or their phospholipid content and vice versa. So what we tell a person right now is in the year 2024, we didn't always believe this. This bad cholesterol had an origin that everybody believed way back when.
Framingham, Mr. Fit, the earlier observational trials, nobody ever adjusted for ApoB in those trials. It wasn't even available when they were doing it. So we now know that the people with low HDL cholesterol who do get atherosclerosis always have high ApoB. And why? Why do those people have low HDL cholesterol? I've already told you it's the trigs that knock the HDL. And the trigs may not be 400.
The trigs may only be 130, which are being ignored. and what is high in them, ApoB. So the proper treatment of low HDL cholesterol in the person you believe has cardiovascular risk is just like trigs, lower ApoB, lower non-HDL cholesterol if you can't get an ApoB. If somebody has a high HDL cholesterol, I don't know what blood test to tell you. I would always check an ApoB.
We do that in 100% of people. And if it was high, we would treat ApoB regardless of an HDL cholesterol level. But I can't look at a man or a woman and say, oh my God, you're the one with high HDLC who might wind up with dementia or some cancer or something. I don't know. So we'll track those other diseases with other modalities that we have at our beck and call
I don't know what to tell you about your cardiovascular health if you have high HDL-C, but I can guarantee you it is not a declaration of cardiac immortality. So it's HDL functionality.
And you recall we had a nice email exchange about a friend of mine who I've known for many years. He's always had a very high HDL cholesterol and a very low LDL cholesterol. In fact, his HDL has routinely been above 100 milligrams per deciliter, and his LDL cholesterol has always been below 100 milligrams per deciliter. So this is a guy that by anybody's metric looks like he's in tip-top shape.
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