Prevent and Reduce Heart Disease, with Dr. Joel Kahn @KahnVideoProductions

Welcome to another episode of the Five Journeys podcast, Live like youe Matter. I'm Dr. Wendy Trubo and my host is Dr. Edward Levitian. And our guest today is Dr. Joel Kahn. And let me just say, he's wicked smart. If you're not from Boston, you got to master the wicked smart. Dr. Joel Kahn is a practicing cardiologist and a clinical professor of medicine at Wayne State University School of Medicine, known as America's Healthy Heart Doc. He has triple board certification in that's why I say he's wicked smart. Internal medicine, cardiovascular medicine and interventional cardiology. He has five books in publication including your Whole Heart Solution, Dead Execs Don't Get Bonuses and the Plant Based Solution and Lipoprotein A, the Heart's Silent Killer, and has hosted his podcast Heart Doc VIP for over four years. Shout out to Marie, who recommended that we get in touch with you. Dr. Khan. Welcome to the.

Thank you, Marie. Thank you, you power team. Very smart. I spent a few months. I finished few months in Boston in med school and they looked at me and said, go back to Michigan.

My dad went to Wayne State.

Oh, good.

Did you know that?

Yeah, I think I did hear you. I do know you, actually. I know Trubos in Detroit. We'll have to talk about that often.

I'm related to all of them.

That's very same street I grew up on, actually.

Really?

All right, well, we'll talk offline.

Oh, my goodness.

Excited to switch conversations.

Five journeys and six degrees of separation.

Exactly.

How about one?

Yeah.

So I. Are we ready to actually have a conversation now?

Hold on. This is the world needs connection and we just figured out some random doctor I've never met grew up on the street that my family lived on. Like, that's pretty damn cool.

Pretty cool.

I think it's amazing. Thanks for bringing that up. Now, Ed, would you like.

I just want to give you a. I get to do this podcast being as appropriate or inappropriate as I want, but I don't have my wife of 41 years next to me kicking my ankles. I give you guys so much credit for trying. I wish you 6 and 16 years of podcast success.

I don't kick his ankles too much.

Bend your heads down. And I'm going to give you the priestly blessing right now that you should sustain and overcome the sore ankles.

With any luck.

All right, I'll talk about my black and blues later. So I'm personally excited because we've been doing the extended current metabolic panel lipid panel for a while and I don't feel like we get to talk enough about it.

Yeah, that'd be great.

I'm really.

It's heart disease. It's heart disease. It's everywhere and it needs to be talked about. So that's why I'm so excited to join you guys.

Very cool. All right, so where do we start? What's a good place to. To start?

Yeah, we should. Can we just. I have a request actually.

Sure.

Can we start with what happens in the body that you start to make cholesterol that people are thinking is not so good. Can we start with the basics for our listeners?

We gotta, we gotta go beyond first. Beyond that. Which is why do we care about cholesterol?

Right, Exactly. And I agree. They're both wonderful entros obviously and truly and always number one cause of death in the western world. Men and women, equal opportunity. We've made a very small dent in that in terms of reducing cardiac death. 2021, number one on the list. For 113 years it has been. Cardiovascular disease is a cause of death. We haven't been able to replace it. Cancer is pretty close. And Covid was number three. The last two. Heart disease is number one. Most people die suddenly. Most people have heart attacks suddenly. It's a wicked dangerous disease that affects ultimately about a third of us during our lives and may shorten our lives dramatically. And we don't talk about it much. We talk so much about detoxification as we should because we all feel tired and bloated and brain fogged and we have to talk about that. And we talk about GI issues and the rest and they're all important. But ultimately your listener always say, I'm very deep into longevity sciences. I'm sure you are. And always kind of assessing what's woo and what's good. If you have not characterized your heart with cardiometabolic panels like you mentioned that with cardiovascular imaging, all of which is not an elite process. It's actually covered by insurance or cash based, very inexpensive. I don't need to order multi thousand dollar panels unless I'm really going to go deep into a mold lime organophosphate biotoxicity kind of workup, which is not my thing. I can evaluate somebody's heart for a few hundred dollars and make a difference so profoundly. And I like to teach it because I can't do all of it myself. So I mean, that's the plea. And where does cholesterol come in? Because it can be, and I say my words very carefully, it can be the cause of clogged arteries that robs individuals of lifespan or quality of life, causes strokes, heart attacks, erectile dysfunction. Let's get below the waistline and less commonly, clogged leg arteries that cause a person to get a condition you're familiar with, peripheral VASC disease.

Hold on, Joel. Legit. Any man who's listening, the only thing he heard was that it can cause erectile dysfunction. I don't think he was like, blah, blah, blah.

Beef burger, cheese, dripping fat and a limp penis is sometimes a relatable and causal relationship. And it can be a clue. That's the important thing. 40% of guys at age 40 have erectile dysfunction. 50% of guys at age 50. It keeps marching up at least some degree and they're enjoying that access to Cialis and Viagra and generics and all the rest. But it's a clue. It's a serious clue that the clogging that is causing artery dysfunction, called endothelial dysfunction. Problem below the waist may give you time to get your heart checked out before you're in somebody's emergency room or somebody's mortuary. In Olmsted county, the county around Mayo Clinic, they published a paper. It's the most dramatic numbers. Men in Olmsted County, Minnesota, that have erectile dysfunction have 44 times the risk of having a heart attack. Of men that boldly answer on the survey, probably because their wife told them to answer it. I don't have any erectile dysfunction. So that's one pathway. Cholesterol is a risk factor. So it means that if your cholesterol is high for most of your life, you might be more prone to develop clogged arteries, heart attack, stroke, erectile dysfunction. But it's one of 25 risk factors. I don't think it's overemphasized because it's one of the risk factors. We can't change you from male to female. We can't make you from 65 to 45, which are all risk factors.

We.

But cholesterol is one of the risk factors that is treatable if it needs to be treated. My clinic is very permissive to walk around with a high cholesterol. But you got to prove to me that your arteries are pristine and not being affected. So cholesterol is a treatable risk factor. But always mention in the same word as blood pressure, blood sugar, your C reactive protein and other inflammatory markers. I want to know your lipoprotein, a genetic inherited cholesterol. And we can go 20 more. So it makes me almost chuckle just to finish this Intro that a internist in the United States does a mammogram looking for a disease or a thermogram. I love it. Does a colonoscopy or a colon guard looking for disease. I love it. Takes out a calculator and puts in 51 HDL, 44, cholesterol, 189, blood pressure 142 over 92, and gets a number and says, John or Jane, your risk in the next 10 years of a heart attack might be about 7.8%, which is a little above average. I'm concerned. Here's a medicine for life. Why aren't we looking at blood vessels? Because we have that technology. Why aren't we doing a cardiac mammogram, a cardiac colonoscopy? All that is basically about a $75 Connecticut scan that hardly anybody gets and everybody should.

We're talking about coronary calcium score.

Coronary calcium score, yeah. Which is being replaced by more advanced cardiac imaging. But it's still the most accessible, most inexpensive, lowest radiation. Since we're not doing hardly anything, let's at least do the almost perfect and very accessible test. And we can leave CT angiography, which is a better test. It's just much more involved, expensive, more radiation. But we need to really ramp up heart disease detection and education and then leave people that don't have heart disease alone if they want to go enjoy a cigar and a burger once in a while. I'm actually not going to give them grief, but I watch my patients with clogged arteries on Facebook in Greece eating cheeseburgers. It's like, oh, man, I haven't done my job. So anyways, cholesterol is a risk factor. And in some people with aged arteries, it's not just wrinkles. I talk about wrinkles inside with age, arteries. It's a very major player that's through diets or lifestyles or supplements and through prescription drugs, if needed, can be managed effectively. I literally, before we log on this podcast, I got an emergency call from a patient of mine about 55 years old. His net worth is crazy. His density of his brain is embarrassing because he's already had stents in his 30s age, 30s. And I've been begging him for years, take some medication. You have genetic heart disease. You can't overcome this with just yoga, yoga, yoga, yoga. Of course, today he had his second and very large heart attack about two hours ago. And he'll be okay, but he's not going to be the same. I've been begging him to get focused on therapy. So it's fun to be anti pharma. I do not trust pharma one iota more in the last two years, of course, than ever. But do they provide no benefit across the board? That would be don't throw baby out with the bathwater when you got serious disease. Precision cardiology, that's the word everybody leaves here with precision cardiology. Let's measure and let's triage and let's not treat the healthy and let's aggressively treat those that are aging internally. But that can be just change in diet, sleep, fitness, toxicity and all that.

So when you're evaluating someone, what's when someone walks in, you want to know if they're wrinkled on the inside. What are you doing? What is it like your hello kind of thing? You're looking at this from hello. What's your pick list?

Yeah, I typically I just go over to a little $5 model. That's what your arteries are like throughout your body. That's your carotid artery, that's your coronary heart arteries, that's your penile artery. And of course there is an equivalent for women. It's just we're not as adept and comfortable talking about it. I'm sure that could be arteries to the other organs of the body and we don't know. Just wheel of fortune. Are you like this all clogged up? Are you like this 50% clogged stress test won't tell you. My EKG won't tell you. We're going to do a very deep history in physical like all good functional medicine doctors do. I mean, I know when my patients have been to the dentist and their root canal history and their silver filling history. And I know their breakfast, lunch, dinner, snacks and cheat foods. And I ask all those questions. But ultimately I'm going to do that very deep cardiometabolic blood panel that Ed mentioned because science and numbers are power and I find nutritional deficiencies in most everybody. But I find genetic the genetics. And just quickly, because we don't have four hours, of course you're going to get a lipid cholesterol panel. And I don't care if you're fasting or not. If you ate breakfast, I want to know if your triglycerides are 700 because you have a metabolic disorder. We'll take your blood when we can get your blood. I'm going to do the cholesterol numbers. I want to know if you have genetic heart disease protein A, a $25 blood test that about 25% of people inherit from mom, dad, or both and could be quite dangerous, but it's still a risk factor. I have crazy patients with crazy high lipoprotein A's and their arteries are fine and we just ignore it. You know, I want to know your inflammation panel. There's a little gene called 9P21. You can get it on the Quest Lab panel and maybe others. Not that expensive. And it's actually the most predictive gene for developing premature coronary artery disease. Except there's nothing you can do about it. You can just tell a person you're at risk and you need to do more with your lifestyle.

Is that on 23andMe? If you had that done, it's on 23andMe.

And it's available from Quest and LabCorp. It's available as a, you know, and then in addition to labs, in addition to history, in addition to physical, we're going to do some vascular imaging. We're going to know by the next visit are you here or are you here? The most accessible way, and maybe your audience isn't to wear because this is 2022 and we still have maybe 5% of primary care docs ordering. But in 1990, a test was developed, a CT scan and you said the right name, Wendy. Coronary artery calcium scan. Sometimes we call it a CAC. CACs. There's about 2,500 research studies in humans on this test. You're on a stretcher. You go in a circular CT scanner. No iv, no injection, no pain, no iodine dye. They tell you to hold your breath for five seconds and you go home. Very often you're wearing your shirt, you might have a couple EKG leads for the 5 second breath hold. The report comes back, same day, next day, your coronary artery calcium score is zero. Meaning by that age in your life, 45, 50, 55, you've not developed bone like deposits in your heart arteries. And most plaque, most disease in heart arteries is calcified. It's not a perfect test because we can't see the other cheese like plaque called soft non calcified plaque. But they usually birds of a feather run together. And if there's calcified plaque, there's also non calcified cheese like soft plaque. I keep saying cheese like because it's probably the major cause of cheese like soft plaque. If you have a calcium score of zero, I might do one other test. It's very simple to do a carotid ultrasound with digital imaging. Everything now is precision, precision, precision. And I'm going to find out. I should definitely cover up this patient's name. If your carotid arteries to your right brain and your left brain are completely clean. This actually a patient I saw this week. 45 year old cannabis magnet in Detroit, owns all of the dispensaries, doing very well. But his cholesterol is 335 and he was referred to me. I'm worried. Well, he has a calcium score of 0 and he has carotid arteries that are like a 35 year old. I can't figure it out. I mean he goes to the right Chaldean church, whatever it is, I'm happy for him. But is he going to get 80 milligrams of Lipitor when he has arteries like a 35 year old? No, we're going to watch him, we're going to educate him on diet.

Any data on THC and cholesterol? Because that would be my first question.

Well, yeah, he's actually not a big user. He's a big seller. He's not a big user at all. There is for your audience that doesn't know this, I'm drinking herbal tea at the moment. I'm a big coffee drinker in the morning. But unfiltered coffee can raise your cholesterol. There's a component called cafestol and you really want to use a drip coffee. You really want to have that brown organic paper collection, the grinds. If either you're putting in ground coffee or you have. I have a Breville that grinds the beans on top. But as it drips through the brown paper, organic paper, it actually captures the chemicals that raise cholesterol from coffee. It's actually true. Espresso raises cholesterol. Filtered coffee, even if it's full caffeine, coffee does not raise cholesterol. It's even to the point. Last year in the European Heart journal they had 25,000 people followed for 20 years. People that drip coffee without a filter versus people that drip coffee with a filter. There was a survival difference estimated in this non randomized study. So thc, THC less. So I just brought up the coffee thing because coffee's always. Everybody loves it, is pretty cool and it's heavy. Heavy.

I have a question about that. Did they include the non coffee drinkers in the study to see where they fell on that spectrum of risk?

No, no. This was because I'm the only non.

Coffee drinker in the world, basically.

You're a non coffee drinker. Yeah. This is a good place to be. And there's lots of all other questions. Keurig cups. I Mean, I doubt you like Keurig cups because you're putting hot water through plastic pipes and plastic cups. I'm not a big fan. You won't find a Keurig machine in my office either. And no aspersion to Keurig. I don't know the family or the business, but I just don't like hot water and plastic. And I know you feel the same way, so. But anyways, that's what people do. People come off and say I feel fine, just check me. And others say I'm breathless. And others say I have funny pains. And of course some have had bypass and it's shocking. And you know this. I am not the quarter last resort, but I'm very often the second to third opinion. Jim, you had bypass 22 years ago. Have you ever heard of a video called Forks over Knives? Do you recognize the name Dean Ornish, M.D. is any cardiologist brought up food is medicine. And it's just as we say here in Michigan, like a deer looking at headlights at night. I mean it's like this lost look at night. And your relatives on the same street I grew up would know what a deer looking in the headlights is like.

Oh, we've hit a couple of those.

We have a lot of deer running around Michigan. So, you know, just. It's a shame we have so much work to do. But early detection, you would like to find out that you have risk at age 35 to 40 so you can implement all lifestyle. I mean you don't need to take pills, maybe a supplement or two.

Do you measure intimal thickness? Are you into.

Yeah. That is again for the audience that doesn't know. I'll cover up. I doubt you can read it through the wonders of camera but it says right here carotid imt, which stands for cimt. T is for thickness. A thicker artery is a sicker artery and you need digital imaging. Just you take a little picture of your carotid, you measure how thick it is. It should be about 0.6 millimeters for pretty much I'm older than you. But for an average age person, if it's 1.1 millimeters, twice as it should be, you're old. In fact, the chart actually there's big databases. You're 48 years old in my clinic and it says you're 78 years old on the basis of your artery age. Very reversible. Very reversible number. I love the test. In very few states. Is it covered by insurance? A standard gradual ultrasound is covered by insurance. The Calcium score is between 50 and $150. And you usually pay cash.

In the state of Austin, it's 300.

Probably they're ripping people off. At University Hospital in Cleveland, they do it for free. If you walk in the University Hospital in Cleveland, they are so committed to the idea that public screening is a value, they do it for free. In the state of Texas, it's covered at age 50 in your insurance program for every citizen in Texas. But in most states, you pay the carotid IMT ultrasound is not covered by the standard carotid ultrasound billing code. It's $150 to $250. It's so valuable because in my clinic, you come back a year later and you've done six different things with your lifestyle, your supplements, maybe your medication. And we joyfully celebrate. Boy, you just dropped seven years of artery age in one year. And I put those pictures on Instagram and Facebook all the time. And I don't see too many other cardiologists. I fully believe Ornish was right. Esselstyn was right. Pritikin was right. Barnard is right. Disease is reversible. It's better to prevent it. I mean, I'd rather catch somebody young. And they always have clean carotids. And I'll just say I'm 63 with a little change. I have not a plaque in my carotids. I have thin carotids. I have a calcium score of 0. I have a coronary CT angiogram that has no plaque. I've been vegan for 45 years. I do work out every day. I have a lot of habits that are imperfect and there's always five pounds. And I'm praying prolonged fasting mimicking diet is going to make go poof. And makes go poof for a little bit and then it comes back. And you guys should definitely have Valter Longo on your program to talk about proloning the fasting mimicking diet.

But we're definitely going to invite him. Tell me how you got into it early.

Yeah, good question. You will relate. I grew up in a home where we did the kosher diet. Not the most popular New York Times book. I went to University of Michigan at age 18 in a undergrad pre med combined program like I think Boston U has. And so I could graduate a couple years early and I couldn't keep kosher at the dorm. So I started eating the salad bar. And anybody asked me, what are you? I said, I'm a salad baratarian. And I went through my training I trained in Dallas, Texas, the home of all kinds of barbecue joints, and I ate okra. I trained in Kansas City to learn how to do angioplasty, the home of Casey Masterpiece. And I ate, you know, zucchini and I just kept to it. And then in 1990, my first three weeks in practice, I'm reading a journal because there was at that time paper journals, not online journals. And there's the Lifestyle heart trial by Dr. Dean Ornish, MD. I didn't know who Dr. Ornish was. I knew some of his co authors because he had a lot of really prominent academic co authors. And that was the famous study that said if you take advanced heart disease patients, often very symptomatic with symptoms, prior bypass, prior heart attack, and you dramatically change their lifestyle, plant based diet, yoga, meditation, group support, some walking, you can actually shrink plaque measured by the most advanced technology in the world. In 1990, I just said, I'm now a interventional nutritional cardiologist. I don't think there was another one on the planet. I'm just going to tell people what I've been doing because now I never told anybody, anybody. I never really discussed diet with my fellowship based patients. But once I got in practice, I asked them to read Dr. Ornish's book and then Dr. Ellison book and then forks overnight. Then I joined a 4M and went through formal integrative training about a decade ago. And it's just, you know, it's, it's a wonderful, slightly expensive way to practice medicine, to spend some time with, you know, with educated and lifestyle oriented people like you. And, you know, and then yet people think I do, like I wear robes and something. I mean, all I do is read science, all I do is read research. All I do is try. I'm usually the guinea pig. I'll go for anything. You've got a new cholesterol lowering drug that's a rectal applicator. Oh yeah, I'm in. Because that's really a true story. It's an amazing compound that actually does work. But we'll do that on the next podcast. So root cause, you know, your patients know it, but your audience knows it. I mean, root cause medicine, what caused you to have old arteries and what can we adjust so they don't keep getting old and maybe we can actually get them younger so you stay away from the medical system. You guys know it. I was a hospital doctor for 25 years, cath lab, er, sorry. Seeing people suffer diseases that never needed to happen. So I'm still planning to do this for a long time because you're turning over one starfish at a time. And we don't have a medical system that teaches what you teach and I teach. We have to seek out, have to go seek out those special clinics like Five Journeys. So kudos for you.

Thank you. You too. Tell me about, I have a quick question about genes And I know Ed has 18 million questions always, but tell me about the, in addition to the one gene you mentioned, are you looking at anything else? Like, are you looking at thfr, like, do you have a gene panel?

I don't. There's probably about six months ago there was an excellent paper and I think it was published out of the Mayo Clinic where they took 800 heart patients and they ran a panel of 162 cardiovascular genes. Wasn't 23andMe they actually found that surprisingly that they estimated that of their patients with atherosclerosis, prior heart attack, bypass stents, erectile dysfunction, again, that 60% was lifestyle and 40% was genetics. That's the highest number ever reported because unless you do a big panel, you're obviously never going to know other than taking a family history and supposing that it's genetic, you're not going to know it. The number one gene on that panel was proved to be this NP21 gene. We still don't know why it raises the risk for atherosclerosis and for abdominal aortic aneurysm, but it's available. And when I get a 41 year old that's had a heart attack and a stent and we're scratching our head, I mean it will be a routine part of my panel. Apoe, did you inherit Apoe 4 or double 4s, which is not a fun thing to inherit, although there's a new phase one research study for people that inherited APOE 44 that I've got enough patients trying to refer them to. But phase one studies are dicey. Everybody gets an mthfr. But I'm not running a full panel beyond that mainly due to expense. I mean I got enough to focus on identify. The only one that's actionable is when I check lipoprotein A blood levels, which I urge everybody listening to ask their primary care, their function medicine doc. You know, I heard about this cholesterol called lipoprotein A. Can I get a blood test or send your blood to lifeextension.com or send your blood to some of the other companies that will let you order your own lab test for a few Bucks. But that is an actionable.

So let's talk about the interventions. What's.

Well, let's talk about why lipoprotein A in particular. Oh, my goodness. I'm the one who went to the basis first. Shocking. Usually you're the one who's like, talk about why, but tell me why that one, right? There's this whole panel we get, why are you picking on lipoprotein A?

So lipoprotein A was discovered in 1963 by a Scandinavian scientist as a cholesterol circulating in the blood, made in the liver, like the more commonly discussed LDL cholesterol molecule, but made in a separate pathway. It's like one automotive line making Chrysler and one line making Ford. 25% of us inherit the ability to make lipoprotein A, which means there's about 1.6, 1.7 billion people in the world are in the United States. 90 to 100 million people in the United States, they have no clue that from conception. And by about age 2, if you inherited lipoprotein A, it's fully being made and circulating your blood. H2, H3, H4, H5. That can cause inflammation. Atherosclerosis, thrombosis can cause your valve, called the aortic valve, to calcify and get premature aortic stenosis, but mainly to cause atherosclerosis. It can be taken up in the wall of arteries, just like standard ldl. It looks like LDL cholesterol with a funny head mask on it. It's got this piece called APOA that is attached. Why lipoprotein A? Because it's extremely common. If one out of every four or one of every five patients in your clinic week, you're going to identify 10, 12, 20, whatever you're going to be telling people. I always chuckle when they're 82 years old and I'm telling them, boy, your whole life you've had this thing. But it's a risk factor. People will live a long and healthy life sometimes with it. But I check their arteries to triage them. Lipoprotein A with premature disease, lipoprotein A with healthier arteries. And then the pharmaceutical industry is three companies right now, Novartis, Amgen, and a company called Silence Therapeutics have actual pharmaceutical drugs because statins don't lower Lipitor, Crestor, Zocor, Zetia, which is not a statin, of course, they don't lower lipoprotein A, and they sometimes actually cause a reflux increase in it. So all those people out there that are taking Crestor, and they've never had their lipoprotein A check. Their LDL goes down and they don't have a clue if they're the one in four people that might actually be having a bit of an adverse lipid reaction with their lipoprotein A Going up, we'll see that change. Niacin lowers lipoprotein A. And I happen to use a lot of over the counter niacin in my clinic, which is unusual, but it lowers cholesterol and it lowers lipoprotein A. Hormone replacement therapy in a perimenopausal woman lowers lipoprotein A. So I refer that out. But I'm a big fan in women with lipoprotein A. I have two questions.

Joel.

Yeah, one.

Can we back up? Well, no, let me start with the quick question for niacin flushing, I'm assuming. Yeah.

Man. I don't have people really. I worry about rash, liver disease, your blood sugar, your uric acid. There is an old fashioned thing. If you take an aspirin before. Nice. And you don't flush, or if you take it in applesauce. And the thing with applesauce is it's quercetin. And quercetin is an anti inflammatory antihistamine. So it turns out so many people are taking quercetin right now as part of their pandemic protocol that actually my patients hardly ever mention flushing anymore. I think it's an interesting little byproduct. It's rare that, you know, I'm a niacin fan. I'll just. In a detoxifying thing, I'll go work out, take 1500 of niacin, and go in my infrared sauna, and I come out like a Boston lobster. I mean, I'm beet red, sweating, and probably just got rid of a whole lot of PFAS and BPA and. And other yummy little critters. Yeah.

So 1500 is around like.

Well, that's a crazy protocol that's been described in Europe for detox. In terms of. My patients are usually 250 or 500 milligrams of niacin twice a day. And I will inch up after that. You know, there's no rush.

Okay. And then going back to what I also wanted to ask about is you mentioned. I just want to make sure I understand this. Lipoprotein A is an inherited state. And so one and everything.

It's a gene. It's a gene on chromosome 6, kind of near the HLA complex. Actually, nobody knows if that's meaningful or not. And there's only four species on the planet, and if I can remember a hedgehog, some of the primates, and I think it's a fruit bat. And humans are the only species that make lipoprotein A. It may be why humans have the ability to clog their arteries and dogs and cats don't have the ability to clog their arteries. In part, it's a strange little beast. With the pharmaceutical industry now fully engaged, Novartis particularly, every doctor in America, is going to be detailed on lipoprotein A heavily in the next three, four years because there is an 8,000 patient phase three study that's actually completed enrollment in people who had a previous stroke, previous heart attack, and a high lipoprotein A in double blind randomized. So there will be a drug called pelacarson unless there's some major signal for harm that I think nobody really expects by about 20, 25.

So if you inherited this gene, you're someone who will make more lipoprotein A than the neighbor who didn't. And how do you test that?

This is also 323 labcorp. No. Lab. No. That's actually a simple blood test. You don't have to check the gene, we're just checking the blood concentration. And if it's elevated, you assume you can check the gene, but there's no reason to. Until we have a CRISPR technology or something like that, there's no reason to. There is no other cause to an elevated lipoprotein A other than genetic inheritance. Or you had a borderline level and somebody put you on Crestor and Lipitor and now you've bumped it up 50%, which isn't always a horrible thing, but it can happen.

Now, I know when we order blood tests, Livipano, we go through Quest and we do the cardio iq, which gives us a fractionated lipids, the April lipoprotein B, lipoprotein A, the plaque crp, et cetera. Are you doing that or you're just doing the standard?

Here's my quest sheet. All right, I'm doing the lipoprotein NMR with lipid panel, but right above it, 91729, is lipoprotein A. Unfortunately, because of the way it's processed, you can't do a lipid panel and a lipoprotein A in the same sample. It takes two tubes. They're very different assays, but they're both very available and inexpensive.

Perfect. Yeah.

So, okay, so basically, if it's out of range, you know you have the genetics and if it's in range, you know you don't have the genetics.

Yeah. And the argument. So like in 2019 the European Society of Cardiology said everybody in Europe should get it checked once probably around age 20. And if you're very high, you've inherited the same risk as a more widely known condition called familial hyperlipidemia. Heterozygous familial hyperlipidemia which can be very devastating cause early heart attacks, early strokes, early erectile dysfunction. United States cardiologists are to going getting slowly and it really isn't the cardiologist. We want the gynecologist, the family practice doc, the internist to really be on the front line or have people just order it. But we're a couple years away. It's going to take as always money. When there's money in the game from an expensive pharmacist advocacy, then it'll be on every lab panel and it'll be in advance because we will find people to treat.

What's high to you? Because you've referenced if it's high. What are you thinking?

Just to confuse. The test has been available for 20 years. It used to be reported out in milligrams per deciliter like a creatinine I think or glucose is milligrams per deciliter and it used to be over 30 is abnormal. Over 50 is at risk. And some people were 2, 3, 400. There's been a change. It's more accurate to report it out in animals per liter. Quest reports in animals per liter. LabCorp does too. Over 75 is elevated. Over 125 is at risk and many people are 3, 4, 5. I've seen a couple around 600. It's a challenge. You can take it out of the blood with a technique called apheresis which is similar to dialysis. There's a hospital in Germany, they have 1500 patients with lipoprotein A that come in every two weeks, get their blood cleaned, their cholesterol goes down, their lipoprotein A goes down and then it just goes back up. Because that's an aggressive approach. This new pharmaceutical, three companies and ultimately some kind of gene editing capability in the next decade will make it a non entity. But it has actually been calculated. I had a heart attack. I'm on all the American College of Cardiology guideline drugs and I have a second heart attack. Lipoprotein A is the biggest piece of that pie that's called residual risk. There's a need to identify it and a need to treat it.

So what do you do to treat it? Non pharmaceutically?

Yeah, unfortunately, it's a pretty common phrase to say it doesn't respond to diet, to exercise, to weight loss. Like ldl, cholesterol will sometimes phenomenally drop with a change from a processed food diet to some kind of whole food diet with fitness, with weight loss. So it's not very lifestyle responsive. And again, most experts would say you don't treat it. I disagree. Coenzyme Q10L, carnitine, niacin, amla, the amla berry. It could be in a powder. You just throw it in your smoothie, lowers it and I get it down. And a lot of people, I get it down. Niacin, as I mentioned, hormone replacement therapy. What I'll often do is I'll take their 40 milligrams of Lipitor, make it 10 milligrams of Lipitor, put it with Ezetimibezetia, and I get the same cholesterol. It's two prescription drugs used for lipid therapy that are very synergistic. But I'm taking their 40 milligram down to 10 milligram of the statin. With the 10 milligram azetimab, I get the same total cholesterol, 135, the same LDL cholesterol, 54. Kind of the numbers we shoot for now. But all of a sudden the lipoprotein A drops because I dropped the statin dose. That's a Con center clinic experiment because, you know, we know it's bad, but there's very few therapeutic trials for lipoprotein A. Essentially none.

Okay, so niacin, it's so funny. I started niacin about a year and change ago and I'm due for my labs. I'm super curious whether it's made a difference. I'm the chosen person, right? I got all the terrible genes, so I got the lipoprotein A, the celiac, the homocyste and got it all. So I'm just really curious, I'm so curious, what effect? Because I've been in the sauna for a year and a half with the knives and I'm curious what effect that's had. So I'll keep you all posted.

Good.

I'm very curious because you have a very provocative. How to never have a heart attack.

Right.

How do you.

I think that is. And I don't believe, as some of my peers that are in the vegan Medical world that I have great respect for who say you're bulletproof if you eat a whole food plant based, low sugar, no sugar diet. They often include no oil diet. That's a point of controversy we might talk about for a minute. I don't believe that at all. I believe you can have a excellent lifestyle and genetics can overwhelm it and you can have a heart attack. So I mean if, if you'll come in at age 40 to 45, rarely younger, and get a good blood panel, get some vascular imaging. Is your carotid showing you're 20 years older than you thought? Is your coronary artery calcium score showing you're 20 years old in your thigh and either do very well on it and come back in five years maybe, or do very poorly on it and institute a plan early, you know, a real precision medicine plan. You have no Omega 3 in your body. You have no vitamin D or C reactive protein. And as you guys know, sometimes it's hard to get these things to improve upon. But you know, I'm sending people for dental CT scans and all kinds. You know, we're chasing everything down we can, but early, putting a focus. When a woman gets a mammogram around age 45, now the new colonoscopy is age 45. People should just assume I need to find somebody to check the heck out of my heart. Certainly if the lifestyle and diet and habits have been bad or if the family history. I had a woman in the office yesterday, her mother had a heart attack at age 42. I mean she's my prime target. I mean she needs to sort out and we can help. Was that mom's poor lifestyle or was mom's genetics? And you carry some of those genetics and it's really, it's a one, two punch, it's a little blood work, it's a little imaging and then I guess punch tree. As we sit down and go over it and make a plan.

What else should people do? Did we skip talking about anything? So we talked about the supplements, we talked about seeing someone, we talked about getting the data. But you know, you get the data and it's not so good. You get the niacin, the carnitine, the CoQ10. Are you advocating for a vegan only diet for people? Where do you fall on that?

This is a bad disease that can be tamed, can be prevented. The only diet plan that's ever been shown to halt and reverse plaque, and I think it's the soft non calcified plaque, is a diet that's nearly completely whole food plant based. I'm the only cardiologist ever to lecture at Paleo FX in a friendly, open minded way and I have and I'm the only cardiologist plant based to be on Sean Baker's Carnivore station and to debate Paul Saladino, the Carnivore diet guy on the doctor show. I will have conversations, be social. I would call Shawn Baker the Carnivore diet actually a friend and all. But when you're going to talk heart disease, we want to talk a thin body. There's a lot of ways to try using diet to get a thin body. When we're talking I had bypass surgery 12 years ago and my doctor tells me to add steak and cheese and your carbs are too high because you enjoy a bean salad. I mean, I've got to spend the time to bring people back to reality that the 95% of the scientific data, it's never going to be 100% because you want to talk prostate cancer, breast cancer. You want to talk about recently melanoma, eating tuna fish and raising your risk of melanoma has been in the news. You want to talk about Alzheimer's, dementia, a largely or completely bright, colorful, organic, whole food plant based diet with most of it home cooking is going to win every time. But I don't tell those that adopt that you're going to be perfect or you won't need to have vitamins because yes, you may be missing iodine or selenium or just simple things to check and correct. So I do think it's the best choice. And I think if you're struggling with weight, I mean there are different pathways for that. But if you're struggling with heart disease, you got to read Ornish's Undo it and Esselstyn's Reverse heart disease and Mr. Pritikin's books. And you got to know who these people are because, I mean, we're talking hundreds and hundreds of scientific studies versus essentially zero for alternative diets. I'll just bring up olive oil has been a bit of a hot point in the vegan doctor movement. The best diet in the world is a whole food plant based, no sos, no salt, oil, sugar diet. Well, that was based on what in my analysis is there some small healthy volunteer studies where they drank olive oil and measured their artery function A few hours later in Spain right now, thank God, they're doing a study of 1,002 people with heart disease. So these are not healthy volunteers. These are heart patients. They get one on A high olive oil diet in Spain or a low olive oil diet. All the diets were low in saturated fat. All the diets were high in complex carb, healthy foods. But high olive oil low. Everything they're measuring was seven year follow up. They actually stopped the study early because there was fewer events in the high olive oil arm, fewer heart attacks, fewer bypass. They had to stop the study early. But when they look at the carotid IMT like you mentioned, Ed, it's actually better in the high olive oil group. When they look at endothelial function a year, it's better in the high olive oil group. But when they actually look at heart attacks and survival, it's better in the high olive oil group. So I don't sell olive oil. I've been called an olive oil snake oil guy. My wife doesn't like olive oil. I'm quite a collector aficionado. But I think when you get a study that defines and has challenged and has refocused us, that you do a 20 patient one hour study and a healthy volunteer compared to these, we need to rethink it. So it's a small little point, but it brings up a lot of country. You know, you talk to Dr. Fasano, who I know you know, or Dr. Longo about Olive oil, they're gonna. What do you mean it's not healthy? It's what, you know, they put it in my baby bottle when I grow.

Now olive oil is. Do they in that study, are they making sure that it's real olive oil?

Because not rancid either.

Yeah.

Combined or.

Yeah, yeah. Every family got a liter of extra virgin olive oil once a week so it couldn't be prepped, you know, fresher. It's certainly. They weren't going to the, to the Wegmans and buying it in a plastic bottle sitting on the shelf for two years. Nothing against the Wegmans. I hope they have high quality olive oil.

Did I track this? So the olive oil was bad? The olive oil was good?

No, that was good. Right.

But Alessio would say it was good too. So that's where I got confused. I was like, wait a minute.

There is this small slice of the plant based medical world because I can. There's a cardiologist, Robert Vogel, he was the director of, of the Pritikin center in Miami for a while who did a fascinating study. It shows up. If you haven't seen the documentary, the Game Changers movie, please watch it. Oh, it's a fascinating diet disease study documentary movie from 2019. But there's a scene where Dr. Robert Vogel, he was my mentor at University of Michigan, long ago. Now he's in Denver. Shows how olive oil may cause some endothelial dysfunction. But again, how many of us take a beaker and drink olive oil like that? Some people do. And I'm not even sure that's wrong, but when you put it on a beautiful tomato, onion, cucumber salad, I mean, you're eating a panzanella salad from Rome. I mean, you're eating it like a Roman.

How can we get high quality olive oil? That's the.

I tried, actually. Remember Nicolette was saying this company, she sent me the link. It's all in Italian. I couldn't translate it. I'm like, okay, we're done here.

Yeah. But she was talking about, unfortunately, I think you're gonna, you know, don't buy it in a plastic bottle. It should be in a dark glass bottle. A lot of them will have organic labeling. And, you know, how do you know your generic Cialis has even any Tadalafil in it? I mean, that's a pharmaceutical representative.

Okay.

Yeah, we're all at some risk, but I probably wouldn't buy my olive oil at cvs.

So the only thing for listeners, I just want to make sure there's. I just had another person yesterday was very surprised. We do not cook with olive oil.

We don't behave that way.

We do not heat olive oil. It's really, really important.

Also, the data is you don't want to fry in olive oil, but you can saute in olive oil. And I wouldn't fry anything.

I think the line. That line is so fine for most people between sauteing and frying that I think you're better off just sort of backing it up and saying, you know, we're not going to heat it because you're going to get too hot.

Yeah. I mean, the best olive oil, you treat gently, like fine wine, which it really is about the same price as fine wine. Cool. How'd you get there? Yeah, I know. Early detection, broad panels of evaluation, big focus on lifestyle. I mean, I always bring up sleep in my clinic, even though, you know, as a cardiologist. And again, you guys, I'm through med school a little bit earlier than you, but what did we learn about sleep therapy? But, you know, it's probably the number first thing I talk about with patients if I can't get their sleep better by a home sleep study or mouth taping. We're a big mouth taping clinic. If you're a Mouth breather. And you wake up with a dry mouth and you're drinking water, you buy either a full mouth tape or these little X's. And for some of my patients think that this has been the biggest health breakthrough because they actually sleep through the night. They don't wake up and urinate all night long. You know, a lot of people read the book Breath by James Nestor that came out two years ago that made a big point. Or Patrick McCow in the oxygen Advantage book and made a big point about mouth taping. It really does help people, some people.

That's so underrated.

Yeah, but, you know, just. Yeah, a cardiologist should be bringing up routinely with patients. When do you go to bed? When do you wake up? How many times? You know, I actually got 100 last night on my Oura ring for readiness. I've never had 100, ever. I posted it on my Instagram account, just not showing off. But I thought it was a terrible night. I had these terrible, strange, kind of. I wouldn't call them nightmares, but movies going on in my brain.

David dreams about his podcast. So to recap, let's go big picture recap. Look, that horse has left the gate because I am way past 40. So basically, whenever you get the message, get your lipoprotein A evaluated. Do your coronary calcium score, have an ultrasound of your arteries, and if anything's not right, get working.

That's absolutely true. And strong family history. If your family history is brothers, sisters, mom, dad, grandparents, aunts, uncles, had early events, do it earlier, do it more aggressively. You know, I'm not the only preventive cardiologist. I'm kind of a reformed. I wasn't interventional, and now I call it interproventional because I intervene all the time. But it's, you know, a beautiful salad or sleep therapy or something. You know, we're working hard, but yeah, I mean, don't assume that is the. Don't assume you'll get burned over and over that just because you look good and feel good, you're good inside. I mean, I hate to say it. It. You may be, but, you know, you're about $500 away, maybe, from knowing for sure. And if you do the calcium score, do the calcium score, you might just be $99 away from knowing for sure. I volunteer in a little clinic in inner city Detroit. I can't order a stress test. They don't have insurance. That's $800. I can't do an MRI. You know, that's $1200. They can afford a $75 CT scan, they're getting better care than some of the executives that are running companies that are doing hundreds of millions of dollars a year. It's a crazy irony that the best test for accurate heart early detection is actually one of the least expensive tests on the panel. Except in Boston, you guys are just, you got to work, of course.

How often do you repeat the calcium.

Score and there's a change going on. I'll bring a really up to date precision cardiologist. There is what a calcium score shows and doesn't show is crucial. So if you're a zero, the scientific. So I do my calcium score about every five to seven years. More like seven, eight years. And that's what the science says. If you're a zero, wait seven, eight years. The amount of radiation from a coronary calcium CT is like a mammogram. Women get mammogram every year, too. We're talking about maybe once every seven years. And really, if you've had two of them and they're both zero, you probably can stop. You know, you're probably not going to develop atherosclerosis. You're lucky you've got good genetics or good lifestyle or excellent doctors at five journeys or something. If it's high, I don't repeat it because it never goes down. We don't really think calcified plaque disappears. I mean, the number of actually verified cases where somebody had a calcium score and the second one seemed to be low are very small, questionable scientific studies online. I will probably move that patient in the next couple of years to a coronary CT angiogram. This is a huge revolution in cardiology. It's a bigger test. You have to get an iv. You get injected with iodine dye, you really feel hot and like niacin for 20 seconds. It's about triple the radiation. It's still not crazy radiation, but it's about triple the radiation. But now using both the fact that the dye enters the coronary arteries and the reports come out telling two things you don't get on the calcium score. How much soft plaque, how much non calcified risky plaque do you have? You can't see it on a calcium score and how much narrowing is in your arteries. You can have a high calcium score in arteries that are only 10 or 20% narrowed. You can have a high calcium score and have 80% narrowed arteries. You just don't know the CT angiogram. With the dye, you know everything. So I wasn't a big order of them except in an emergency room setting or somebody with previous bypass or I want to know how many were open. But now there's an artificial intelligence company called clearly I'm not an investor. C L E E R L Y. They're in New York City. They'll take your CT angiogram, run it through this crazy analysis. And I'm sitting down and telling my patients now, it's like cancer grading. You have stage four coronary disease because you have 822 cubic millimeters of plaque, 600 cubic millimeters of soft plaque, 222 cubic millimeter is hard calcified plaque. You've got a 47% narrowing in your proximal lad and a 18% narrowing in your mid right coronary artery. It's really like on drugs. So if I have those at risk patients, particularly if they need motivation, what's your level?

How high of a calcium score do you want to get up to before you start hitting the pain?

Calcification of coronary arteries is age related phenomenon. So we usually say your calcium score is 122 and you're in the 92nd percentile for age or way above average. I'll treat them for a year or two, then I will order anything over 100. And that's a pretty arbitrary cutoff, but anything over 100.

All right, Joel, this has been amazing. Where do you want to direct people to find you? What's the action you want people to do from here?

Yeah, we'll do all these steps. I would like to tell you it's easy to find doctors that share my philosophy. It's not licenses in about 30 states, so I do quite a bit of telemedicine, but I have a clinic in suburban Detroit. Khan longevitycenter.com K A H N longevity center.com and we see people. It's fun, you know, from the Philippines and from Israel, but, you know, mainly from the Midwest, but coast to coast and also I'm very reachable by email. Drconcenter.com d r k a h n@khan center.com People ask me, do you think there's somebody in my town that can arrange it or what are the questions I need to ask? I'm not flooded with those questions. I really do answer myself. I have a podcast every week, Heart Doc, vip. I'm talking about this week, the new diabetic drugs for weight loss, Wegovy and Tirzepatide, the brand new one that's not even fully FDA approved yet. I think it's interesting to see how we're going to fit in these new drugs into weight loss management because. Because even the whole food plant based diet, God knows not everybody loses weight or any of the other diet approaches.

All right. So we will put everything in the show notes.

Cool.

And I will close out the show. Thanks for listening to another episode of the Five Journeys podcast live. Like youe Matter. If Today made a difference for you, please give us a five star rating and tell all your friends so they can have transformation too. Our guest today was Dr. Joel Kahn. And we were just delighted to talk about heart health, lipoprotein A, and how.

To live and live well. Well.

So thanks for being here. Have a great day.

Thank you. It's been a pleasure.

Thank you.