A Cardiovascular Surgeon Had a Heart Attack Here's What His Own Tests Missed

You talk as a cardiovascular surgeon about how you want to make, you know, heart disease the number 2 killer in the world, not the number 1 killer. But the irony is you had a heart attack. What are the factors that people should be paying attention to? Because this is really a preventable condition.

If a farmer looks out on his fields and all of your crops are sick, where's the first place they look? It's in the soil. Being mindful of what you're putting in your mouth, focusing on a whole foods diet, limiting ultra-processed foods, limiting saturated fats in your diet. You got to be so careful these days with the more extreme choices because you always have to be careful what you're substituting things for, 'cause it's something that we have such control over.

Jeremy, it's great to have you on the podcast. Thanks for coming all the way from Georgia.

Thank you.

You know, your story is quite compelling. You know, we were just chit-chatting a little bit before, and you're a cardiovascular surgeon. You do bypasses and you, you know, fix arteries and do major big surgeries. Let's say cardiovascular surgery and brain surgery are like the two top surgical specialties that, you know, are really tough and hard to learn and that take a lot of time to become expert at. And somehow in all that process, you discovered that you were kind of treating things at the wrong end of the stick. You were kept seeing over and over cases coming back over and over with bad habits that they never changed and needing another surgery, another surgery. And, and you did that for a while, but it, it sounds like you had your own epiphany in medicine where you realized you might be not thinking about things the way you should. And the, You had your own health crisis. You talk as a cardiovascular surgeon about how you wanna make, you know, heart disease the number 2 killer in the world, not the number 1 killer, which is a great aspiration. But the irony is you had a heart attack. So tell us about that. And I mean, you look healthy, you, you seem healthy. I'm sure you don't smoke. I'm sure you eat pretty good and look fit, exercise, like, and you're kind of the, you know, the kind of person you wouldn't think would get a heart attack. But here you, you were and you had a heart attack. And that's kind of what I wanna get into a little bit on the show, which is why are so many people who seem and look healthy getting heart attacks?

It's an ongoing question for sure. And to make it even more egregious from, from my standpoint, the timeframe between making that shift of treating the endpoint of disease and when I actually had my event was another 10 years later. So I was already very dialed into, you know, really, really working on solid lifestyle choices And I thought that I was doing a really, really good job. I really did. And what I have come to learn is that none of us are immune to cognitive dissonance. We know better, but so often we just don't do better. It can be simple things. You know, the smoker knows they shouldn't smoke, but they continue. You know, you shouldn't reach for the chips, but It's what's convenient. You're tired. You deserve them. However you defend that. And no one knew better than me. Yeah. The signs and the lead-up. I mean, I lived it, I taught it, I dealt with it.

Yeah.

And like I said, what did you miss? Intellectual honesty. And I fell deeply into that gap of knowing better and not doing better.

And what were the things you weren't doing that that led you to have a heart attack? It was only 2 years ago, right? It was like—

It was 3 years ago. Yeah. Well, it really, it didn't hit me until after the event because it was really in the midst of it that I fell, kind of first tripped into the space because I woke up one morning with what I thought was just reflux.

Heartburn. Heartburn.

And I get up early, I was pacing around the room and my wife's like, are you okay?

I'm like, yeah, yeah.

I get a little reflux. She goes, You don't look like you have reflux. I'm like, seriously, you're gonna tell me I'm a doctor that I don't have reflux? I mean, come on. So I sat down, I read for a little while, felt fine. Took the dogs out for a walk. It was December. We get a quarter mile from the house. It was cold outside. I'm peeling my clothes at this point, sweating. And she looks at me, she goes, reflux? I was like, yeah, you know, it's just really— she's like, okay. So we go back to the house.

Is she a doctor too?

She is not. She's just an incredibly brilliant woman. We get back to the house, and not to be overly graphic, I sit down on the toilet, and within 30 seconds of sitting down, symptoms went away. And I immediately was like, no, exertional symptoms relieved with rest? No, not me. It's not possible. Couldn't be. Could not be. So At that point, I did what someone who is the poster child of cognitive, cognitive dissonance would do, and that's explain it away. And through the course of that entire day, I would go upstairs, have it come back a little bit, and I'd sit down and it would go away. Oh yeah. That evening, my family went back into town and I was with my youngest son and we were out in the woods that evening, dark. He's 14 years old, quarter mile from the truck, no cell service. And I go down on my knees with significant chest pain. Like I knew what was going on. And my son's like, dad, are you all right? Like, what's going on? I said, oh, it's just reflux. He goes, you can't walk around when you have reflux. I was like, oh, you're another smart one in the family. So I pull myself together. I get, we get back to the truck and I drive home.

Oh man.

Oh yeah. I'm gonna lay it all out for you. I didn't say I was gonna be proud. So I get home, I take a beta blocker and an aspirin, and I go to sleep.

Oh wow.

Wake up the next morning.

Not the right decision, but good thing you woke up.

I share it. I share it hoping that others will do other. Sometimes you need an example of what not to do.

They call, they call, you know, the, they usually say the first symptom of heart disease is sudden death for 50% of people. And, and I've had peop— people I know who's had that experience. And you're lucky you had some warning signs. They call it the silent killer, but it's, in your case, it wasn't so silent.

And about 5 or 6 years prior, we had a good friend who was a radiologist at 48 that that's exactly what happened to him. So it's not like I'm not aware. I woke up the next morning. We live in a home with staircases, went down to make my coffee, came up, same symptoms. So then I had to come clean. And my wife says, this has been going on since last night. Why didn't you, why didn't you say something? She said, well, you would've made me go to the emergency room.? And she's like, well, that's what you do when you're having chest pain. I said, well, I didn't like the cardiologist that was on call that night. She goes, are you kidding me? She's like, you're friends with all of them.

Yeah.

Yeah. And then she stopped for a minute and I always kind of get goosebumps. She looked at me and she said, that is the most selfish thing you've ever done to me and the boys.

Yeah.

And that really, that hit hard as you might imagine. And I said, I hear you. I am terribly sorry., but can we go, can we go to the hospital? So I call one of my buddies. He's like, there's no way, man. I said, I'm telling you. I said, I've tested it pretty good here. So he's like, come to the office. I'm like, oh, I don't think that's a good idea. He goes, no, no, no, no. Just walking around the office, he took one look at me and I was in the cath lab and, you know, one stent in the right coronary, you know, and, and I was fine. So I wouldn't let him sedate me. You know, for the procedure, cuz I wanna know what's going on. So he passes the wire across it, which occludes the coronary.

And you had severe chest pain, EKG changes, severe chest pain.

And I'm like going, hey man, hey man. He pulls the drape back. He goes, I need you to shut up so I can get this done. Sedated me, got it done. Went out and told Tracy, I dream of stenting cardiac surgeons, but doing anything to your husband was an absolute nightmare. She goes, oh, I'm sure. I'm absolutely sure.

So, so what were the things that you did that led up to that? Because you obviously have been in this field, you're aware of heart disease, you're not doing the normal bad things.

It's really only in retrospect now that, that I was able to really unpack all of that for myself because the immediate response was, I do, I have a stressful job and certainly a component, but not enough to really lay your hat on. The second was after 25 years, And you're still doing cardiac surgery? Oh yeah, yeah. I went back to work that Tuesday after, as soon as they would let me. So, my sleep was totally out of whack. I was on DEFCON 1 all the time. So, I was like, okay, that's certainly a risk factor. If your sleep's off, everything's off. Certainly a risk factor. Well, it really wasn't until we started with the platforms. And my son Max was instrumental in all this. You know, he said, Dad, wouldn't it be interesting if like you put on a CGM? Wouldn't that be interesting? I was like, Max, if I need to show you what a great job I'm doing with my diet, with my exercise, that's fine. He's like, Dad, I don't care what it shows. I just think it'd be cool, like, show people, you know, the process and look at your numbers.

Yeah.

Within 48 hours, it became very clear that my baseline glucose was unacceptably high. Checked the A1C, I was 5.7. Flipped into a fasting insulin level, which I'm embarrassed to give you the number.

Come on.

I'll say it was—

Come on, give it to me.

40.

No. 40?

40.

Seriously? I mean, just for those listening, it should be less than 5. The lab reference range is 18, which is I think terrible. 40 is Is high. You, you were what, you had a little belly or what?

You know, not a lot of sugar. Really?

No bread, pasta, rice.

Not really. And so how come it was so high? I don't really have that answer, but I definitely retooled my diet as a result of it. You know, using the CGM, I was able to kind of see like, and I added 10-minute walks after meals. I tried to add more cardio, back off on some of the strength training. I used to do a lot of endurance work. And that made a difference for sure. My A1C came down to 5.5. We got the, you know, the insulin level down to acceptable ranges. So more risk factors than were obvious. Again, look healthy. Yeah, but you don't know until you know. And we'll add the coup d'état on top of it, which would be an ApoB of 180.

Wow. And you had checked it or hadn't?

LDLs— oh, LDL-C only. Which was mildly elevated around my event, mildly, my triglycerides were a little high, which is in line, of course, with the, the insulin resistance and all those things, but not shockingly so. It wasn't 500, it wasn't in line with that.

What was your triglycerides?

I don't remember. I want to say they were probably upper 100, 200. So yeah, yeah.

I mean, high, but not, that's high. It should be under 70.

Right.

But the lab reference ranges, you know, would say 150 is okay.

You're not gonna cut me any slack today. No, here I am pouring myself out to you. I'll give you an example for other people.

It's amazing. You're, this is important information because you're, you're highlighting the fact that you're here, you're a cardiac surgeon, right? You're into functional medicine. You're trying to do the right thing. You know, you maybe had a few things off of your diet, but you, there was something going on. It could be other factors like your microbiome or toxins that can cause insulin resistance. For sure. But like your, your numbers were numbers that most people don't look at, right? And I didn't, you hadn't even looked at. I didn't, which is amazing. Yeah. And you know, ApoB is now, which is this, it basically a culmination of all the, the we call atherogenic lipid particles. So triglycerides and LDL particles and, you know, intermediate density particles and so forth. Lp, these are all together in ApoB. So it's, it, it's now recognized by cardiologists as being the most important biomarker for predicting heart disease risk. But it's almost never tested by traditional doctors. It's just, they check you take your regular cholesterol panel and that's it. And yours was a little bit off, but not terrible.

Yeah.

And here you are sitting on a time bomb and you're lucky you didn't actually have a, a clot and die. I mean, you could have.

Absolutely. And it goes back to that, you can't fix what you don't measure. And it really took me understanding that my priorities needed to change, that I truly needed to engage in secondary prevention. And to do that, I needed to know what my numbers really were. And the grace at this point is I have now normalized all those things. My particle counts are really pretty phenomenal on Repatha and a little low-dose Crestor.

And it's really important what you're saying is, 'cause you know, looking at you, no one would say, oh, here's a high-risk heart attack patient. You know, you don't smoke, you don't have high blood pressure. You're, you know, you're, you look fit, you seem, you know, into health. But like these things are under the surface in a lot of people. And we're seeing this a lot with Function Health. We're seeing a lot of people who we're now measuring this on. I mean, I've been doing this in my practice for 30 years. I've been measuring lipoprotein little a, measuring particle number, particle size, even when before that was a, when it was a company called Liposcience, which did this particle numbers and size before LabCorp bought them, before Quest developed their tests. I've been doing this for decades and measuring ApoB and all these numbers. And it's amazing to me that they've been available. But I mean, I sat with the head of the executive physical at Cleveland Clinic who was an older gentleman who remained nameless. And I was like, listen, I think your executive physical labs are a little dated. Maybe you should do, you know, particle number, particle size, you know, ApoB and all this. He's like, well, you know, we don't like to do things before there's adequate research. And I'm like, well, this has been around for 40 years. Ron Krauss has discovered this 40 years ago that particle size and number matter and they track with your carbohydrate intake and not fat. So like the, if you're eating more starch and sugar, you're gonna have more of these atherogenic particles. You're gonna have high Lp, you're gonna have more particle number and smaller particle size. These are all the things that no one's looking at. So I think, you know, getting these things tested is so important and at Function Health, that, that's what we do with everybody. And we're seeing it's huge, huge number of people who have particle numbers that are high. It's over 90% have really some degree of abnormality. And when you map it to like imaging, Then you can actually see what's going on. Sure. And then, you know, you can treat it like you, you might have some genetic factors. There's lipid genetics that play a role, I'm sure for you. I certainly have like a, an inherited familial lipid disorder. It's not like class, the classic one, but it's now we have more genetics we can do. I've done my full genetics for lipids and, and, you know, we're gonna be offering, you know, genome, whole genome sequencing soon and so forth. Like I think we're seeing a lot of, of, of potential to really understand your unique biology and then how to customize treatments.

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And I think you make some really interesting points. Like, take Lp, for instance. I mean, it has really been around for, for decades, a long time, and at least as long as I've been doing medicine. And if you look at the history of that, of, of why it didn't come to center stage, and I'd be interested to know what your thoughts are on this, but it was that attitude of, well, we can't do anything about it, so why should we actually be testing for it? And I mean, that's, that's such a misguided mindset because, you know, knowing something is, is as important even if you can't do anything directly about the thing, you know.

Right.

Like having that information so that you can change everything else. Right.

You can reduce all the other risk factors.

Exactly. And even with the inherited factors, the other inherited factors, that's such important information to be able to stratify people that otherwise look healthy, that, you know, you need to get those numbers lower, that you need to be more thorough, that you need to be more engaged so that you don't end up in, in the situation.

Yeah. Because I'm sure those numbers that you had, if you've been tracking them for decades, they would— you would start to see the trend line going something like this for sure. That's what's available to, for people for a very low cost. I get Function Health, we basically do a dollar a day. You can get all this stuff done.

Sure.

And you know, twice a year testing and get a really deep view, not just of, of your, you know, your lipids, but also like metabolic health, which is, you know, you, you kind of, you're a case in point that most heart attacks today are really, aside from the small subset that's just inherited lipid disorders, it's coming from metabolic syndrome, from prediabetes, from poor metabolic health where we're eating so much sugar and starch that it's causing high insulin and high triglycerides and high ApoB and all these things that, that are really from what we're eating.

Things get misconstrued many times because they come in, you know, patient, two patients, right? You have the healthy 50-year-old that has normal standard panel, physician shakes their hand and says, you're good to go. And 18 months later, that patient's in the back of the ambulance with a heart attack and the response is, C, LDL doesn't matter, cholesterol doesn't matter, none of those things matter. Then you have the other patient that had high cholesterol, was well treated, has LDL levels of a 15-year-old, also in the back of the ambulance 18 months later. And that patient's response is, I was safe, I did all the things. And they're both wrong.

Why?

Well, because the truth is somewhere in the middle, right? Because LDL just doesn't tell the whole story. Now, before, you know, we break, you know, before we attack LDL, clearly LDL is causal. We have lots of data that supports that, but it's not the whole story. ApoB, Lp, the metabolic components, you know, that, that's a very, very important component. This, the second arm of that is the things we can control.

And we've over-indexed on LDL because we have a drug that treats it. The truth is that that may not be the right target for treatment. And when you look at the data, like even things like triglyceride to HDL ratio is far more predictive than LDL. And, and, and, and, and that's a reflection of metabolic health. So high triglycerides and low HDL means you probably are heading towards prediabetes and that's really the driver. You're, you sort of mentioned people can have normal cholesterol and have a heart attack or have, you know, treated cholesterol and have a heart attack. There, there was a big study that was like looking at, I think, maybe you know this study, I think looking at 130,000 people who were admitted the emergency room with heart attacks. And I think 75% had quote, normal LDL, but only like, I don't know, 10% had normal triglycerides or something like that. It was like, it was so—

It's just not the only villain in the room. And for most of us, myself included, that certainly was the case. And I think that that's the reality. And that's understanding that you we can all fall into this gap. Recognizing it before we do, understanding what we— what tools we have available, whether you can move the needle with lifestyle changes, or you do all the foundational pieces, you eat well, you move, you sleep, you have your relationships in check, all those things, and you're still not right. You know, it may be time to consider a different lever. You know, people today think that taking medication is a failure.

No, it's not.

It's not. And it's both the fault of patients and physicians.

Yeah.

You know, I think about it like a, like a scale, you know, at the one end of the patient scale, you've got the individual who's like, just treat me, doc. I'll do whatever. I'll do whatever you say. And at the other end is, I don't want anything to do with medication. I can do all this myself. Somewhere in the middle is where we need to be. Well, the physician scale is not very different. You've got on one end the physician that's giving out medication like it's a Pez dispenser. And I think honestly more—

What's wrong with Pez? I ate that when I was a kid all the time.

It depends on what's inside when you eat it.

I haven't heard that phrase. You're mouthful. You're welcome. I haven't heard that. I don't know. Do they still make those? I'm like—

I have not seen them nor have I looked for them.

For those that don't know what that is, it's a little thing you had when you're a kid. It was like a little device that popped out a little candy and you could just pop it and it would pop out a candy. And that's exactly how they hand them out.

And at the, you know, at the other end of the spectrum, and I think this is actually a much more dangerous mindset for physicians, is we'll just watch this and wait. You know, you're doing great, continue doing what you're doing with abnormal labs. And the problem is that's, that's like patient-centric care masquerading in this other form. And in the end, these are risk-benefit decisions, right? Like, yes, do the foundational things, do all the things that you need to do, but if that's not working, you don't leave your patient at risk. So both Both of those things are really at center line is where they belong, somewhere in the middle.

It's true. There's a real need to know what your numbers are and use those to guide you as opposed to, you know, just you look fine or your basic cholesterol panel's fine. Because that, like you said, for you, yours was a little off, but it wasn't terrible.

That's right.

And I think that's the way it is for most people. And so, so I think the key here is tracking your trends over time. Because if you were 30 and you track your numbers, you'd probably start seeing them go a little off. And then by the time you're 40 and then 50, and then, you know, you're getting into your upper 50s, then you really already have the disease. Like you already had a problem. So really you wanted to start checking this earlier, right?

For sure. And I think that my personal mindset is that atherosclerosis is something we have. It's not something we get. You know, if you look at autopsy studies from 3-year-olds, there's a fatty streak in the aorta. If you look at the P Day study, you know, autopsies from trauma in the field, 18 to 35-year-olds have early changes in their coronary arteries. Now, none of those things are causing any problems at that age, but the propensity for that is already there. Our goal is to get the runway out as far as we can to not have problems. How do we make choices that push our body in the right direction? Not the right— we stay in that. That's the thing.

So right now we know enough. Like we know enough what to track, what to measure, how to test people. For sure. We can talk about imaging a little bit, but we also know that cardiovascular disease is mostly preventable. I mean, I remember, I remember learning about William Osler when I was in medical school and he was one, you know, the first textbook of internal medicine. He was at Johns Hopkins, this kind of very iconic physician we all learned about. And I remember reading about how when they would have a heart attack patient, it was a huge deal and they would have the whole staff run, the medical students, the residents, the doctors, the attendings would all come around and see this patient because it was such a rare condition. It was rare to have a heart attack back in 1910. Sure. You know, maybe if you were eating really crappy diet, which was unusual, cuz you, you could, yeah, if you were rich and had a lot of, you know, money, you could buy a lot of expensive, you know, starchy foods, whatever. I don't know. But the point is now it's so prevalent and, and we, we have to sort of be more, more diligent about actually helping people map out what their history is over time and tracking that. But what, what, what are the factors that people should be paying attention, paying attention to? Because this is really a preventable condition. I mean, you, you're saying you want to take heart disease from number 1 to number 2. What What would be required to do that?

Yeah, I think you started the foundation and this comes back from my time with you at the functional medicine conference back in 20 years ago. Yeah, yeah. It was in Baltimore.

We were young bucks.

Yes, yes. I was going for early morning runs around Baltimore. It tells you I wasn't so smart then either. But really, start with the foundational pieces. And I remember a friend of mine said, he was a wise, is a wise gentleman. He said, if a farmer looks out on his fields and all of the, if all of the plants are sick, if all of your crops are sick, where's the first place they look? It's in the soil. What are we feeding the plants? Sit in the airport, watch our fields go by. So I think that being mindful of what you're putting in your mouth, focusing on a whole foods diet, limiting ultra-processed foods, limiting saturated fats in your diet. You got to be so careful these days with the really kind of more fringe type choices, the more extreme choices, because you always have to be careful what you're substituting things for. And so I think that that's I think it's a great place to start cuz it's something that we have such control over.

Yeah.

Right. And I think our gut is such a primary source, not that we understand the microbiome fully by any stretch of the imagination. Yeah. But I think the principle really holds, you know, our, our, what we feed ourselves is our cells is the information that we're going to give our body to live on. It's, you can connect those dots. I think most of, most of us can connect those dots. And when you're thoughtful about it, you just feel better. I mean, I've had personal experience with that. Clearly movement every day is critical, both aerobic training and strength training. They're great independently, but compound dramatically when they're put together. My personal Achilles heel, sleep. You know, I can tell you when your sleep is off, everything is off. And for me personally, It's the hardest because I can control what I put in my mouth. I can push myself to go to the gym. The harder I try and control my sleep, the worse it gets. So I've had to change my relationship.

What have you done that's helped it?

The biggest things I've done is changing my sleeping environment. Dark, cold, taking a hot shower before bed so that I know that I'm— my body temperature's going to drop to help going to bed at the same time every night, setting alarm to make sure I'm going to bed at the same time. As well as waking up at the same time, trying to get outside as much as I can just to get sunlight in my eyes. And can I tell you that it's perfect? No. Is it a lot better? Yes. And again, know your numbers. You know, I followed— I've been following my HRV, my heart rate variability, which is a wonderful indicator of your autonomic nervous system. Since you are pushing me for my numbers, I will tell you what they were and what they are now. My HRV was running between 15 and 17.

Yeah, yeah, yeah, yeah.

Higher the better. And now I'm running in the mid to upper 30s and occasionally I'll hit a 50 if I really am well hydrated. So I'm on the right track, but is it? No, it's not.

It's always a work in progress.

I am definitely that.

So really this whole epidemic of heart disease is largely preventable if you address diet, if you exercise, if you sleep, if you manage stress, if you avoid smoking. Yes. If you manage your blood pressure, which also is a big factor. Absolutely. And it's very much related insulin resistance and prediabetes. And this whole same phenomena is what causes high blood pressure. So these aren't all separate problems, blood pressure and heart disease and high cholesterol. They're all like, they're all kind of one thing.

Nothing happens in a vacuum in the body. Yeah. You know, it's one big ecosystem.

And so, so when you try to start to knock off all these factors, you can start to really change things. And then also, you know, connection, community, stress is a big factor. I think a lot of people are lonely and that it's like smoking 15 cigarettes a day in terms of its effect on your health. And, and there's a, There are interesting studies looking at the gene expression patterns under stress. When you're lonely or isolated, you produce more inflammatory genes expression. So you have more inflammatory proteins out there in your body and causing more damage. And I, and we know heart disease is an inflammatory disease, right?

For sure.

Maybe, maybe you can talk a little bit about that. 'Cause I think, you know, we used to think that it was just plumbing problem. You know, you were, you're a plumber essentially. You're like, oh, I am do cardiac bypasses and open up arteries and fix aortas and fix, you know, femoral arteries and all these things that, that get clogged up. And so it's, it's kind of like a plumber going in and rerouting the pipes or opening up the pipes and cleaning 'em out. And, and the truth is it's not necessarily just a plumbing problem. It becomes a plumbing problem, but it starts off as an inflammatory problem. And there's ways to check that. So tell us about the role of inflammation in heart disease and also about how do we measure that?

So I, I wanna separate the, the roles of inflammation and heart disease because I think that there is a bit of a misconception. In, in the lay public when it comes to how we think about systemic inflammation versus specifically what's happening at the arterial wall. So when, when we talk about the inflammatory process, specifically when a plaque or a blockage is forming, the wall of the artery is penetrated by an ApoB-driven molecule, lipoprotein, if you will. That then sets off a cascade of events. One of which is an intense inflammatory reaction in the arterial wall, which draws those inflammatory cells into that area, which then starts this cascade of collection of more cholesterol, a healing process that then starts. And it's that healing process many times where we start to see the, the actual stenosis forming. So we have a local form of inflammation that's result of an injury repair pattern. If you will. But the question is, what made the arterial wall vulnerable in the first place? And that, I think, is a distinction that people don't truly understand. Right. So if we break down what's actually happening, there's two components: the artery wall's being attacked, and then it's the integrity of your endothelium or that in the intima, the inside lining something that is either capable of fending that off or it's vulnerable. So it's the balance of those two things. I think that, that you have to kind of separate what's happening from an inflammatory standpoint. 'Cause if you talk to a pure lipologist, they're gonna tell you CRP doesn't have anything to do with, with, you know, creating a stenosis. Well, specifically, they're not wrong.

Yeah.

You know, you're, you can't having that inflammatory process in the wall of the artery isn't gonna show up. On a CRP.

Yeah.

But, CRP tells you what the general environment is.

What the general environment is. However, my perception of how to utilize this is it's an indicator of your endothelial resiliency.

Yeah.

What are the things that are keeping the endothelium intact that are guarding against those outside forces? And, when you have insulin resistance and metabolic syndrome and inflammatory factors, those are— look, we know that just elevated chronic glucose alone is impacting the vessel wall. Yeah. Again, making it weak, making it more susceptible. And that's why it's, it's, it's an equation really. It's very, it's more of a heuristic than it is an equation because it's more of a guide, you know, just to understand that these are balances. So when we start to talk about those things, like What can we do differently? Exactly what you said. How do we, how do we put the fire out that is creating this vulnerability that then creates a, a ripe environment for injury to the wall itself?

Yeah. I mean, that's, I think that's an important distinction between, you know, the inflammation happens at the local level and systemic inflammation. Yes. That sets the stage for things to go wrong.

Yes.

And, and the, the, you talked about insulin resistance, you know, prediabetes, insulin resistance, belly fat, those, that belly fat's producing a whole cascade of inflammatory molecules is spewing out through the whole body and is causing havoc everywhere, including on your arteries. And that, that's, you know, that, that's really people to understand that sugar is inflammatory, that sugar and starch are inflammatory. And that's a lot of what's driving it. Obviously it's pollution, it's stress, it's, you know, microbiome. There's a lot of other factors, but, but that's predominantly what it is. And I think, you know, most heart attacks probably before the last, you know, 60 years were probably not metabolic syndrome. They were probably different.

Yeah.

You know, they were smoking, they were, you know, people were thinner. They didn't have all this sugar and starch. It's, I think it's changed. I, I, I think you should be looking at it. It's, it's changed. And what's interesting is that doctors aren't measuring insulin and they're not measuring insulin resistance.

Mine had never, mine had never been measured. Yeah. Until, until, and here you are a cardiac surgeon.

Yeah. And probably the most important predictor of whether you're gonna get a heart attack is your degree of insulin resistance. And yet it was never measured, which is just sort of staggering.

Yeah.

There's actually a new test that we offer through Function Health, which is called the Insulin Resistance Score, which is a, it's, it's the most accurate measure of insulin resistance that we have now other than more of an interventional lab test, which is called like a euglycemic clamp test, which you wouldn't do as in a research study, but it's, it, it's better than the calculated version. We used to call it HOMA-IR. Mm-hmm. Much, much better than that. And you can now measure using a C-peptide level and an insulin level using mass spectrometry. And we offer it through Function Health. And it's, it's amazing to see how, you know, where people are on the spectrum and then you can actually monitor it like an A1C and see how it changes.

And I think, and I think that that's been one of the biggest limitations with the insulin level is the lack of standardization. Across labs. You know, what do the numbers actually mean? What's the standardization? So I think to have something that's got some real data behind it's going to be really powerful and something that we can actually count on.

Yeah, it is pretty exciting. So now with the deeper diagnostics, with becoming more affordable, with accessible diagnostics, people can actually know what's happening. And I think people should start early, like get a baseline in your 20s, see what's going on. You know, and I think, you know, the heart imaging Testing era is also changing. Yeah. So before you'd have to do an angiogram, you'd have to stick a big catheter in a guy's groin. You'd have to shoot dye up there. You put a lot of x-rays on, it was like a whole thing. And then you, it wouldn't that accurate a test. Often you'd miss stuff that was, you know, concentric plaque or you'd miss some stuff, you know, then, then they developed like more interesting tests like a CT angiogram and they now have AI Mark. Enhanced CT angiograms, which are really interesting. So you can look at soft plaque and hard plaque, and now we can do also a chest and heart CT scan looking at calcium in the heart. How do you use the imaging, like this, the coronary calcium score or the AI enhanced coronary angiograms on CT scan? How do you use those?

So I think that this is very much an evolving an evolving space very, very quickly. And as you pointed out, it kind of started with the early, the early CT calcium scoring only, then to CT angiogram, et cetera. Now I will say that coronary angiography is still the gold standard with FFR measuring, measuring actual drop in pressure across stenosis or questionable areas using intravascular ultrasound. I think that there are ways.

Yeah.

Are ways that, again, like the imaging has progressed for the less invasive or non-invasive, it's also progressed, it's also progressed on the other side to address the things. So I think these things are, are complementary. I think that for sure, until we added CT angiography, really knowing soft plaque is so important. Now knowing calcific, uh, plaque burden is helpful as a screening test if you're out out totally normal or on the other end of the spectrum. It can get really gray and can really confuse things sometimes in asymptomatic patients without any symptoms that are in that middle ground. It can, you know, it can, it can require further investigation. But as—

like a CT angiogram.

Exactly. Yes.

Which is a good screening test.

That's exactly right.

And if it's abnormal, you want to follow up.

Exactly right. And now with this AI Mark component, I think it's gonna, when you can digitize the information and you can actually not miss the calculation, it's not— it becomes less of a subjective reading and more of an objective reading when it comes to actual measurements. The accuracy, I think, of those tests is going to change dramatically. Now, how is that going to look clinically? What is that going to look like for outcomes? All of those things are— that's why I say I think it's just an evolving space right now.

And it's important because, you know, I'm sure you've seen patients like this, but, you know, I have patients who have perfectly normal labs but have plaque and clogged arteries and people who have even the labs you would expect would be abnormal or people who have terrible labs and whose arteries are normal. Like, yes. And, and I'm like, wow, you have a high particle number. You have high ApoB, you have high Lp. I'm like, you should be having a heart attack right now, but you're 65 and your arteries are clean.

Yeah.

So I think for me, what it's taught me is that I can't really put people on a lifetime prescription of a medication unless I know the anatomy because cholesterol is a risk factor. It's not the problem. Yeah, it's a risk factor.

Sure.

And sometimes it's high and sometimes it's not. Sometimes, you know, treat— treating it isn't the real solution is figuring out what the other causes are and, and treating those like insulin resistance.

And I think you make a great point. I mean, it's like every decision we make in medicine is a risk-benefit decision and you, you know, you have to make certain that you're maximizing benefit that and minimizing risk and you're mitigating in favor of that patient. And you can't rely on just one number or even two numbers. You know, each patient is so dramatically unique and different. Just because there was a pulmonologist who said to me years ago, he said, Jeremy, the protocols are the practice of medicine. Knowing when to and when not to apply those protocols is the art of medicine. And that's what you're talking about.

Yeah.

It's like if you followed the protocols, and there's nothing wrong with that, we all follow the standard of care protocols. Those are our guidelines. But if you plugged that patient into the protocols, you would've put that patient on medication right away without any additional information. If you had only, because, but you were thoughtful about that particular patient.

Yeah.

And I think that that's so incredibly important. And one of the things that is of concern for me as I look at medical education moving forward, because there's such a high reliance on protocol-driven medicine, which is wonderful.

And what's the baseline? It's not, it doesn't, it doesn't go deep enough. Like if it's a place to start, follow the standard protocol, you're not getting lipid fractionation, you're not necessarily checking ApoB, you're not checking Lp, you're not checking insulin levels, you're not checking insulin resistance scores, you're not checking All these other things that are so important that have to be part of a full clinical picture to make a decision. Right. That's what worries me. It's not, it's not that it's not the good starting place, it's just it's inadequate.

Yeah.

Yeah.

It's, I think that's, yeah, I think you're right. It's not that it's wrong.

Like, the number one medicine right now is LDL's high, statin. Like that to me is completely screwed up.

It, it's not wrong. It's incomplete.

Yeah.

You know, I think is, is the way to look at it. And you know, at some point, you know, maybe listen to the patient. Examine the patient, you know, do the things that you— be a doctor first and then understand how to put all these things together to make, to make the best decision. Discuss it with the patient, God forbid, you know, and let them be a part of that decision-making. And I, you know, I think that's one of the great things about, about Function Health, right? It, it allows patients to regain a fair amount of agency in their own healthcare. And I think a lot of patients want to do that in this day and age. You know, I think that, that people are frustrated because access is such a problem. You know, pick up the phone and try and get an appointment with your primary care physician. It's hard. And I'm not suggesting that it's intentional. They're busy and they're seeing a lot of patients and, and it's tough. And I think that, that to really regain that agency and to take full responsibility for your healthcare, you have to have options to be able to actually follow through with that. And I think I think that's one of the great opportunities that, that Function Health offers.

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It addresses some of the gaps, you know, some of the gaps that are out there in terms of how we're trained as doctors, how we approach prevention. We're kind of in a reactive system, not a proactive system. And I think about heart disease. I mean, by the time you have plaque, it's late in the game when you have a— like what you had with the symptoms of chest pain and needing a stent. I mean, that's kind of down the road. And who knows what would happen if you would've found this when you were 35 and you'd done a heart CT where you did a calcium score and you had your ApoB checked and your insulin checked. You're like, oh. And I think that's where we are now in medicine, which is that we have to have more agency as individuals and not just rely on the healthcare system. Because the training's going to take a few decades or generations to change. It takes a long time for medicine to change.

It's turning a battleship. You know that better than I do. I do.

Yeah, I tried. I was Cleveland Clinic for 10 years. It was a very big battleship.

Yeah.

And they were very open. It was great. We did a lot of great work there, but it was also, it was very hard to get people to change how they think, you know, to really do more of a proactive approach. I want to sort of talk a little bit about this set of idea about this person who looks healthy having a heart attack and what you would advise people to sort of check because like, You know, for me, like I exercise, I'm, you know, my body fat is 10%, I eat healthy, like I shouldn't really have a problem. So why would I bother checking? But actually I did check. And because of my family history, like everybody on my grandfather's side dropped dead in their 50s, I'm like, I got a problem. So I've had to manage it. And I think, you know, I wouldn't have thought I would be a person who would have high risk, right? Because I've been running since I'm 14 years old. I've been eating healthy my whole life. I've been, you know, And just, I mean, yes, I'm stressed, like sleep issues 'cause I'm being a doctor, but, and life in general. But like, I, it was, it was interesting. So what would you advise people who are listening who think they're healthy? What should they be doing? What should they be checking? What should they know and when should they start doing it?

Let's start with the simple things first. Get a blood pressure cuff at home and check your blood pressure. You know, if you can't do that, find a friend that has a blood pressure cuff and take it on a regular basis. You know, It's, it's really the silent killer for a reason because it's not a problem till it's a problem. Most, 50% of Americans have it and many Americans don't even realize that they have it. And it's the most modifiable, the most easily modifiable cardiovascular risk factor that we have. And it's just back to that same tenet. If you don't measure it, you don't know. And it's so easy. And doing it once at your primary care visit is not, is not enough. You know, you need the 7-2-2 rule, you know, for 7 days, twice a day, 2 measurements, record them, take an average. That's what your physician really wants to know and what they need to know to be able to come up with an accurate number. So I think that's a great place to start and to really potentially move the needle because it's such a significant component of cardiovascular.

Yeah. And then blood pressure is not just random, it's caused by certain things, right?

Absolutely.

You can actually figure out too.

Well, that'll come to the next. Next suggestion, and this goes along with the, the how we look issue. It's not always your weight, it's the distribution of your body fat. And that's why I really recommend that people are checking their waist-to-height ratio. Very simple to do at home.

And that tape measure is a very cheap medical device.

It really is. Be honest about where it is and where you're measuring.

Belly button.

That's me at the belly button. And, and you don't want your number to be greater than 0.5. And that's just an indicator again of, you know, the amount of intra-abdominal fat, that visceral fat that functions really as an endocrine organ if we look at it for what it's actually doing. And again, what you're saying, it's, it's a, there's drivers of all of these things and they're also interconnected. So I think those are two very simple places to, Blood pressure and waist to height. Blood pressure and waist. And then you get down to—

And waist to height would be waist in inches and height in inches.

That's right. Or centimeters in both.

Yeah.

You know, just keep the units the same.

Yeah.

So that you make sure it's a, it's an actual ratio.

And that it should be less than 0.5.

Exactly. And that gives you something to really follow and track progress, both blood pressure and something that you can do at home. Yeah. You don't have to go to a physician's office. You don't have to do any of that. You know, from there, I think we, we look at some of the specific labs that I think people should be checking. I think an ApoB is crucial. Lp, for sure, at least once in your lifetime because it is a genetic factor. I think that menopause may change those numbers slightly. So I think for women, it directed by your physician, it may be best do it pre or perimenopausal and after, after menopause as well.

Yeah.

There may be some ways to modify that. There's also new drugs that are coming around that might be helpful for that.

And, and absolutely. And now they're, they're coming outta phase 3 clinical trials. It'll be interesting to see where those end up because the question of course will be just because you can lower Lp, what are the outcome studies that are gonna be as a result of that? But story's still to be told and, and very promising, which is Great. I think that that's very useful. I think knowing your hemoglobin A1C and some form of fasting insulin is just really, really important. And I think if those are really the core that are not on a standard panel at all, CRP is kind of plus minus. I think there are a lot of primary care who are starting to do it. Those are really not, unless there's some trigger for hemoglobin A1C, they're just not.

They're not checking it. They're not checking it. They're not checking them, but be—

Mine wasn't checked. No knock on my primary care physician, because I'm sure there's—

No, we're just not trained that way. And these are really affordable tests. I mean, they're all included with all the things you mentioned are included with a lot of other tests, like 160 tests for literally just a dollar a day, $365 a year for twice a year testing. It's not free, but it's not that much considering what people spend money on coffee and whatever they spend loosely money on. It's investing in your health. And you know, sometimes the doctors won't do it. I met with the Dean of the medical school at, in Bentonville, the Dallas Walton School of Medicine. And she's, she was, she's a, I think a gynecologic oncologist. And she said she's, she's of Indian descent from India. She went to the doctor, to a cardiologist, said, I want you to measure my insulin. He's like, no. And he wouldn't do it. Really? And he's like, yeah, well, we know at lower body weights, we get more insulin resistance. So like, I want to check get? And he was like, you don't need it. I mean, just that level of just, she said she went to her doctor and said, I want to get my vitamin D checked because I don't feel so great. I'm a little tired. So you don't need it. She's like, I don't care. I want it. She said, well, insurance won't pay for it. Well, she says, I don't care. I want it. She got the vitamin D and it was zero.

Oh, wow.

Because she was, you know, dark skin, lived and worked inside, you know, didn't go out much, you know? So I think we're missing so much. And that's, that's, you know, really why a company like Function Health that I co-founded has really started to give people agency to know what's going on, to not have to be someone like you who's, you know, at 57 has blocked arteries and wish they could have figured that out sooner, right?

Absolutely.

Hopefully your son's getting all those tests.

Oh, and then some. He's, I think he is going to be a lipologist before the end of all of this. I can tell you because he probably knows more about lipid metabolism and genetics than I do at this point.

Is he a medical school?

He is not. No, he is not.

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You know, you spend a lot of time like fixing damaged hearts, like literally, and you now want to help people never have surgery. So how do you think about really move— putting that mission and moving that into the world? Like coming on my podcast is great. You're writing a book, you have a website, you have a podcast, but like how do you see kind of doing this for yourself?

Well, I hope that sharing my story and being willing to allow people to peek behind the curtain, if you will, that, and admit that none of us are immune. It may not prevent people falling into that cognitive dissonance gap, but you will think about it.

Yeah.

You know, so my hope is that I can raise awareness and then By, by really trying to communicate relatable, high-quality health and wellness information that's really tactical in people's lives, you know, and the world that we live in right now is so maximize, maximize, maximize, maximize that everybody feels like they're, they're taking a test. And if they miss one thing on the protocol that they failed at that and just give everybody an opportunity to let their shoulders down a little bit, take a breath, and know that if you miss, you know, if you miss one workout, you haven't failed. You're just going to come back the next day and start over. And to help people really integrate that into their lives, the really foundational pieces, and then helping them understand, well, what's the next layer of that? Okay, you've, you've done the work. Check your blood Check your body fat distribution, check your labs. You can't fix what you don't measure, right? Be proactive about, you know, atherosclerosis, which is something that we know we're born with, something we have. It's not something we get. We get the problems.

Yeah.

Can we keep inflammatory factors at, at the lowest? Can we keep our insulin levels where they need to be so that we don't have problems? Comes at 57 years old.

Yeah. And true. Very true. All right. Let's do some rapid-fire questions. You ready?

I'm ready.

Okay. So what's the single biggest mistake people make when it comes to heart health?

They think it's not going to be them.

Yeah.

They convince themselves that I'm fine. I'm fine. Yeah. It's just not going to happen to me.

That's, that's an important one. Cause a lot of people stick their head in the sand and they wait till it's too late and medicine just doesn't seem to focus on prevention. So what's one What's one heart health myth you wish would just go away?

The one that I deal with on a regular basis is that patients that come in with heart disease and get a stent or bypass surgery think they're cured. And I always tell people, we're not treating the underlying problem. All we're doing is getting you out of trouble. You now have to do the work because the process is still going on.

You think when you crack somebody's chest, they change their lifestyle, but you wouldn't think—

Most of the time not, because I think there's a misunderstanding that they think we've cured the problem.

That's right.

And really all we've done is gotten them out of trouble. We can save— we can save you. We can't heal you.

And when you tell them that, do they get it?

It depends. You know, it depends. I mean, I lay it out. I say, if you— you're going to continue to smoke, all bets are off. We've taken all this upfront risk. I'm not going to soapbox you about smoking. This is your decision. These grafts could be down in 6 months if you continue to smoke. Look, we've taken all this upfront risk for an operation. You don't want to be back to do it again. But I think that's one of the things— it's, it's more of a misunderstanding than it is a myth, but it's become kind of the perception.

What's the most underrated habit for preventing heart disease?

Uh, 10-minute walk after meals.

10-minute walk after meals. Why?

Because it keeps blood sugars under control.

There you go.

It keeps your blood sugar and insulin— yeah, because your, your muscles can take up glucose without actually needing insulin, which is amazing. But insulin obviously helps. But it's, it's, it's true. I think it's a very simple habit. Yeah. What's one food you wish people would eat more of?

Fiber.

Fiber. Why?

Well, because it helps control blood sugars. It helps, it helps with cholesterol metabolism. Metabolism. It satiates you. And so you eat less. It's, look, it's not sexy, but, and it's good for your microbiome. And it's, it's critical.

I agree. I agree with you.

I agree. It's critical for your microbiome.

I agree. And the side of, the side effects of eating fiber is eating a lot of other plant foods that you're looking for. Exactly. So it's like, what, how about what do you wish people eat less of?

Saturated fats.

Saturated fats. Okay. We didn't really go into that too much, but you know, there's been a lot of controversy about saturated fats.

Yeah.

And there's been— I'm a believer.

I think it's, you know, I'd love to hear your perspective because I think my understanding in literature and also treating, you know, thousands of patients is that it's so individual.

Yes. Yes.

Like I had a patient who, a patient who was an overweight woman. She had high triglycerides, like 300. Her HDL was like 30. Her, you know, particle number was high. She was insulin resistant. She was pre-diabetic. She had A1C that was up. And I said to her, look, she was struggling with weight loss and just couldn't knock it down. And I said, well, why don't you try a ketogenic diet? And I put her on coconut oil and butter, saturated fat. Her LDL came down 100 points. Her triglycerides came down 200 points. Her HDL went up 30 points. I was like, and she lost 20 pounds and her insulin resistance went away. That she went on basically a ketogenic diet with saturated fat. Another guy was a thin biker. He's like, I heard this keto diet's great. I don't know, I wanna try it. I'm like, I don't think you need it, but like, okay, but let's monitor what you're doing. And he was riding his bike 50 miles a day. He was like super healthy and ended up causing his cholesterol to go exactly the opposite direction. High particle number.

Mm-hmm.

You know, lots of small particles, high LDL. I was like, wow, okay, so there's a lot of genetics involved here and, and different people respond differently.

Exactly, exactly. And I think that that's why following the biomarkers are so important. Yeah, you know, but I— my impression is that if we look at the bell curve and we look at the majority of people and how they're going to respond with saturated fats, they're going to fall into a place of, of concern. I don't know that they're going to fall into those, those outliers. I think it's more of a, more of a risk factor than not, But you don't know until you know.

Okay.

What about saturated fat versus sugar and starch? Who's worse? Which is worse?

I mean, I think it would depend on how much of each. I think if you're gonna eat only saturated fats, you better follow your biomarkers very closely. If you're gonna try to cut out all of those things and you're gonna shift to, you know, eating a lot of higher carbohydrate foods, you need to follow there too. You need to be following your blood. I think, I think there's a balance. Between those two.

Yeah.

Check your numbers too.

Yeah. Check your numbers because we all metabolize differently.

What about non-negotiables in nutrition? It's just like something you never do.

Mine's pretty general. I adhere to an 80/20 plan. I do the best I can 80% of the time, and I know it's not gonna be perfect, so I grace myself for 20%. That's my non-negotiable.

And the 20% is what is, you're not having Twinkies?

No, I'm not having Twinkies. It's bread or pasta or a piece of cake at a birthday party. So real food, real food, but not ultra-processed food.

Exactly.

Exactly.

Essentially removed ultra-processed foods.

Yeah. I think that should, just for people listening, that 20% should not be soda or industrial processed food.

Yes.

Because those are deadly and they're not actually food by definition.

They're edible food product.

I mean, it's true. If food, if I, you look up the Webster's dictionary definition or Funk and Wagnall food, it's definitely not what ultra-processed food is.

Sure.

That's defined as something that supports the growth and health of an organism, which none of those things do. What about in terms of exercise, cardio? Or strength training?

Individually, they're strong. Together, they're exponential. You know, I really, if you look at the data, the VO2 max and aerobic data is certainly very potent and, and significant when it comes to decrease of cardiovascular events. There's no doubt about it. We look at cardiovascular health and when it's measuring how efficient our cardiovascular system is, what does that equate to? That equates to ejection fraction or how much heart is being pumped out of the heart with each beat. We know that ejection fraction is directly related to longevity and survival. So, the data is powerful there in a connect the dots very—

And the cardio.

Cardio. It really is. But, when you look at strength training and we talk about muscle and it being the sink for glucose in our body, it's like they're so hard to separate. I get asked that question all the time. And, And I just, look, we're all drawn to one or the other. I'm working with this woman now, she is an endurance runner and she hates to do resistance training.

Yeah.

I'm like, you have to do resistance training.

That was me.

That was me.

That was me. I was 40, skinny, could run a lot, but could bike 100 miles, but like, well, because I couldn't do 10 pushups.

And I did the same thing. I was an endurance athlete. And I think that physiologically we're very fit, but mechanically we're not. And that comes to being able to do things as we get older. But more importantly, we know we lose muscle as we age. We know how important it is. For overall metabolism.

It's true.

I definitely, I've indexed way more on the cardio for most of my life. In the last 5, 6 years, I've been more on the strength training.

Yeah. Same.

Okay. What about a piece of advice that every 30-year-old should know?

That it's, it's never too early to start because the deadlifts you're doing at 30 ensure that you're able to pick up your suitcase at 80. The, the, the aerobic training you're doing at 30 is what's gonna enable you to travel and have the endurance to be able to do the things. The decisions you're making now are not going to just impact your overall cardiovascular health, but they're going to change your functional capacity later in life. It's just—

If you want to enjoy the fruits of your labor when you're older, you have to take care of yourself when you're young.

That's right.

I see that often. People like run themselves in the ground, they retire, and then they just can't do anything.

That's right.

Yeah. What's one thing you wish every 6-year-old would know?

I would flip that corner around. It's never too late to start exercising. Either. And we know the data with that, right? We know that you take 55 and 60-year-olds that have never exercised in their life and you watch how their heart function changes in a very consistent regimented program. It gets stronger. So it's never too late, but start small. Yeah. Make it fun. Pick things that you want to do. Pick things that are enjoyable for you.

I love that. I love that story of like the guy's 65, never exercise, starts rowing, and now he's like fitter than most 30-year-olds, you know, like he's 95 years old.

Yeah. Well, and remember too, like particularly in the beginning, that's when they see the biggest benefit.

Yeah.

When you've gone from never exercising to a consistent program, they get a huge— but so it's never too late to start.

All right. Now, as a heart surgeon, what's, what's one thing you avoid?

There's so many things I gotta pick one, huh?

Or maybe how about this? What's one thing you avoid that you actually like that you don't wanna avoid?

Well, I'm gonna, I'm gonna, I'm gonna zoom out. Way, way far on you. The one thing I, I avoid is complacency because I think that that's a very, very dangerous place to be. And I think that's very much where I ended up because I felt like I was checking all the boxes. You know, I was doing triathlons, I was, I was competing at the iron distance, I was doing all this, doing all the stuff, right? But I became complacent in, in how I evaluated things. And to me, The willingness to change is what allows you to grow and to change and to change paths as the road changes underneath you. So I avoid complacency.

That's good. I like that. I like that advice. And lastly, if there's one biomarker you get to pick as a heart doctor that everybody should check, what is it?

ApoB.

ApoB. Okay. Everybody get their ApoB done. Yeah. Okay, great. Amazing. Well, thanks Jeremy for sharing your story. Thanks for your vulnerability and getting other people to think differently about this. 'Cause you know, you've been at the, at the shit end of the stick of the plumbing problem in heart disease for a long time. And I think, you know, waking up to the fact that this is actually a preventable disease, that we actually could move the needle on this, that if people actually knew what to look for, what to do, what to measure, and how to change their habits, that we could actually beat this thing.

Well, thank you so much for having me. I really enjoyed it.

Thanks, Jeremy. Yeah, man. If you love that last video, you're gonna love the next one. Check it out here.