Tests for Assessing Cardiovascular Risk

So we're talking about the importance of knowing which labs to get done, what tests might do to predict future cardiovascular risk. Now I really think about a lot about longevity and we have a practice that focuses a lot on looking better on the outside cosmetic things. But I'm really spending most of my time thinking about how do we help people look better on the inside, which be less cardiovascular disease, strokes, heart attacks, less cancer, and less neurocognitive decline. So how do we screen for cardiovascular disease in America? Well, really, we don't. We do some things that are pretty useless. And we still have cardiovascular disease being the number one cause of death in America. And even with all the advents of stenting and cardiac bypass surgery, the rate of cardiovascular death is roughly the same. We spent $600 billion treating it and just maybe extending people's lives a little bit, but not meaningfully eliminating it. So there's three ways you can screen for cardiovascular disease that your doctor might not tell you about. One is called a CAT scan or a calcium sc. That's probably the most crude measure and it's beneficial for people that are very young. But it does pick up calcium spots in the arteries. The disadvantage is that it might mix. It will miss soft plaques and you can't track it. So but that's one thing you do just to screen. I'd say before 50 years old, that's a good test, about 99 bucks. Another one is called the CIMT Crowded Intimate Media thickness test. That's something we commonly do where you look at the thickness of the bulb and the internal media, internal media of the, of the carotid artery, which is a good signifier for how much cardiovascular disease even have your whole body, that's normal. You don't have to worry about your heart. If it's abnormal, we should be starting worrying about our heart. And the next step after that, that's abnormal. We do what's called the Clery study. C L E E R L Y. This is a special artificial intelligence CAT scan with, with the contrast that straightens out the arteries and shows the amount of plaque and artery. What is the plaque made of? Is it soft, which is dangerous, hard, which is okay. And you can also track it along. So I'm going to tell you about a study that's not yet been published. I do have the information from the lead cardiologists of the, the centers that are located throughout the country that have the Clery studies. And they pulled data from their patients profiles and compared it with their Clery study. And about 4,000 patients. Okay. And these are the things that correlated most with cardiovascular plaque or cardiovascular plaque volume. So the plaque is hardening of the arteries or atherosclerosis. If there's no plaque in your arteries, you're not going to have a heart attack in the next 10 years. Very, very unlikely. If you do have plaque, your rates go way up. Okay, so we want to screen for this. So what tests correlated with cardiovascular disease? Okay, number one, hemoglobin A1C. This is something you test to see if you're diabetic or pre diabetic. That had a very high concordance. That was a 30% correlation with having an abnormal Clery study. So hemoglobin A1C. Ideally your number is right around 5, it's over 5.7, you're pre diabetic. Over 6, you're a diabetic. We want that number to go down. Okay, so that's something you can track. Homa, which is just another indicator of insulin sensitivity. Very strongly correlated. Now, oxidative apob, which your doctor does not generally check for, that was strongly correlated. This is a more sophisticated test. Uric acid. Uric acid, which we think about in gout. Actually, a normal uric acid might be a problem. The higher the level, the more inflammatory it is. We want that number to be around 5 or below. So that's a good number. If it's higher than that, has about a 20% correlation with cardiovascular disease or a plaque homocysteine. There's some of us that have some genetic mutations. I certainly have them. It was called MTHFR mutation. Strongly correlated with cardiovascular plaques, insulin level. So higher insulin level, more cardiovascular plaques. Again, now drop down from there. What are we checking? Ldl, very weakly correlated with cardiovascular disease. High sensitivity. C reactive protein, Very weakly apob. That's what your doctor might check. Apob, which, not doctors don't check it, but I do. Apob. LDL and CRP are very weakly associated. What is virtually not associated with cardiovascular disease? Cholesterol, triglycerides, almost no correlation. So the things we've been routinely checking for way down here, which are useless, and some of the things we don't routinely think about as being associated with cardiovascular disease. Very important. So your hemoglobin A1C. This has got to come down. If it's high, it's got to come down. There's medications you can use, there's lifestyle interventions you can do. Might have a genetic predisposition for A high hemoglobin A1C. I certainly do. My mom, dad, brother, sister were all diabetics. Both my mom, dad passed away but they all had diabetes. And I'd make sure I keep my level, you know, five or so. This oxidative, oxidized apob that's not being checked full routinely, that's something you have checked that's different than the regular apob which is way down here, uric acid, something we don't really think about much. So check your uric acid level, get that down around 5. There's, there's a drug, alpurinol that can be used to lower it if it is on the high side. And it's not perfectly safe drug but it's generally safe. There's certain, certain problems with it with this rare skin condition. You talk to your doctor about that. Everybody should have a homocysteine check. We want that down below 10. And then your insulin level does correlate to this. But resting fasting insulin level and fasting glucose level aren't as strongly correlated to cardiovascular disease as hemoglobin A1C is. And that's because insulin and let you fluctuate a lot during the week or during the month where these are kind of steady states. So if you want to know if you're at risk for a heart attack in the future, which is really a big way to lengthen your life is not to die of a heart attack because we can see these decades in advance and we can intervene decades in advance. Your insurance company is not going to probably pay for any of this prevention. They might pay for some of this blood work, but the cleary steady you can get it done. I'm dictating this from Michigan. We have a clery machine in South Southfield at the Ascend Ascension Health Center. There's other places around the country that do these things right around $1500, that's about a one minute study. They do give you a very low dose of radiation, so safe amount of radiation. And there's a contrast typically. I have a family history of heart disease, what's called the heart attack gene. So I've been really worried about that. My dad and all his brothers had heart attacks before they hit 50. So I've been really been watching it and I do have a little bit of plaque volume in my arteries, my heart and my carotid. I've been reversing those over time. So when I started really checking this was 2018 and my cardiac age was two years older than my personal age. That really concerned me because I'd been doing things to Reverse my cardiac age without measuring it for a long time. Once I finally measured it, it's like I got a problem. I'm aging faster than my years. And I was able to reverse that by about 16 years through intervention. I'm not gonna go my intervention because it can be different than yours. But one thing is keeping this as low as possible. I've been spending a lot of my time down in this cholesterol area which I which I've really managed personally. But now I'm realizing the importance of hemoglobin A1C. Want to make sure that stays down low when you do your A1C. If it's higher than you want it to be, I recommend wearing a continuous glucose monitoring device. It goes right on the back of your arm. They're $75 at Kroger. It's a two week device that gives you a continuous measurement of your blood sugar. Now what does that tell you? Well, it tells you what foods you probably shouldn't have eaten. So personally I would tell you that I have a bagel in the morning once in a while. Bad idea. Spikes my blood sugar up really high. Some people might not affect at all. So I know probably should not be going for the bagel in the morning. We find that if you are going to have bread with a meal it's best to eat it during the meal for most people. But you can test it yourself. So with the, with the continuous glucose monitor you put on the back of your arm. I don't have one on now or periodically is touch your phone to it. It gives you the last eight hours recording using the Freestyle Libre 2 week one has the. It's the easiest to use. Your doctor has to write your prescription for it but you can just pay cash for it. If your insurance doesn't cover it. I recommend doing that like every four months or so. Just kind of give you a reminder that should and should not eat. And that's really the most effective way to lower this. If you're not in the diabetic range, if you're in that diabetes or pre diabetes range, we definitely recommend you go on medication. Be it metformin or semaglutide or something similar. The two most effective for lowering open A1C with along with diet and exercise. And if you do have diabetes, you know, diet and exercise is extremely important. But you should go into medication to give you a little bump, give you a bump down. If you're net, you know, 5.4 to 5.7 range you can and you're Overweight, you should consider some, some of the semaglutide or tirzepatide, but certainly lifestyle intervention to get that down because that's a smoking, smoldering and causing cardiovascular disease. So this is based on the most advanced way to predict who's gonna have a heart attack. And these are the ones that are most strongly associated with having a heart attack. This was not a study to say what happens when you lower this, how does it affect that? We can make certain speculations. We'll have this information down the road. But we know that a person that has diabetes, high hemoglobin A1C, it goes on a drug that lowers the A1C, they add years to their cardiovascular health, actually add about 1.7 years to their lifespan. So it's important that we understand that we should be looking for cardiac disease before it occurs again. The methods will be a calcium score of the heart, which is a CAT scan. If your score is zero, that's great. There is some misses on women and potentially African American. There's a little bit less, there's a bit more soft plaque which will be missed on CAT scan. But that is a good, still a good screening tool because it's so inexpensive. It's usually about $100 widely available, not covered by insurance. Next up from that, which is a significant step up, is a CIMT carotid intima media thickness ultrasound. You can't get it done in a hospital. Typically you got to get it done at a cardiologist or a functional medicine practitioner that does preventative health. They're usually about $300. Again, your insurance won't cover that. Looking for heart disease is not considered medically necessary by insurance company. And the next step after that, which I don't think is the first step, but is the Clery. If your CIMT or calcium score is abnorma, do the Clery scan. It's about 1500 dollars locally and that'll give you a really detailed view which your arteries look at. I did mine two years ago, had a little bit of plaque, not much, but enough. I'm concerned about because I want to live a long time healthy and I'm planning to do it again this fall and hopefully it's shrunk. I did a pretty aggressive intervention the last two years to shrink that and I checked my CIMT that has gone backwards 16 years. So I want us all to have the same opportunity to reduce our chance dying of a heart attack. So thank you very much.