February Town Hall: Heart Health Month

All right, everybody. Welcome. Once again, this is Northern Virginia Family Practice’s monthly town hall. Very excited to have everybody here with us this evening. We have a really exciting conversation and discussion to follow.

I’m Dr. Cesaly Habert. I’m one of the family doctors over at Northern Virginia Family Practice and I’m really excited to be joined this evening with Dr. Arzu Jangiri. I’ve known Arzu for several years now and we collaborate a lot and I’m just really grateful for all the time and expertise that she offers to patients and also helps me learn more about cardiology in general.

Just a little bit about Dr. Jangiri. She’s a native to the DC area, born and raised around here, but also Richmond, Virginia. She went to school at Virginia Commonwealth University and did her residency in internal medicine and fellowship in cardiology. She now works for Amelia Heart and Vascular up here in the Northern Virginia area. Dr. Jangiri’s passion is in preventative cardiology, which is a lot of what we’ll be discussing this evening, as well as cardiac imaging and heart failure management. She’s often heard saying that she treats her patients like they are her family, and from what I know of Arzu and our years together collaborating, I know that that’s true — and it’s also what I hear from my patients that I’ve sent to her.

Thank you so much, Arzu, for being here. I’ll let you go ahead and get started on this discussion about beyond traditional risk factors for heart disease. We’re going to be talking about several new markers that we’re using to help assess our risk. Take it away.

Thank you so much and thank you for that warm welcome. I’m very pleased to be here this evening to talk to you all, and thank you for taking the time to join this discussion. I’m happy to take any questions at the end because a lot of the stuff that comes up for patients when I see them is something we do see in the presentation, and I’ve definitely saved time at the end to take your questions. I’m happy to stay as long as needed.

So like Dr. Habert said, we’re going to talk about some of the risk factors beyond what you get in a traditional evaluation, just to maximize our ability to help patients and ultimately reduce the risk of having cardiac issues in the future. Let’s get started.

So, why don’t standard cholesterol tests tell the whole story? The number at the top — that 50% of heart attacks occur in people with normal LDLs — can seem a little alarming, but we do see that. There are a lot of factors that go into people having heart plaque buildup and heart attacks. If it was just about lowering the LDL, then we would just give patients medications to drive the LDL down as much as possible. But we’re learning that there has to be more involved and we have to do more testing to figure out what else is there and what else we can do to help our patients.

The standard tests are important and very crucial, but you can have plaque building up silently in your arteries. There are other particles out there that could be involved in plaque formation, and chronic inflammation can also be a reason that people develop these issues. So these are some of the tests that we order for patients to look at that.

One of them is a calcium score, which is a low-dose CT scan that tells us about plaque buildup. Another is lipoprotein A, which is an inherited genetic particle that’s not part of a standard lab test but can be elevated in one out of five people. And then high sensitivity CRP is an inflammation marker that can be elevated in patients that have a higher risk of having plaque rupture and heart attacks.

So how do we assess patients right now to look at their heart? When you come into your primary care doctor or a cardiology office and you see your physician or provider, we do blood work, we take a history and physical, and from there, when we see your panel, we make some risk assessments. The first step is to look at the patient’s age, their total cholesterol, how their blood pressure is controlled, diabetes, if they are a smoker or former smoker, and family history. Based on previous studies, there have been data points that we get from these calculators, and it gives us a percentage of having a cardiovascular event — defined as a heart attack, stroke, or vascular event — in 10 years.

Less than 5% is very low risk. We say just continue lifestyle modifications, which is eating well, exercising, sleeping well, and not doing any illicit substances like smoking or heavy alcohol use. High risk means you should definitely be on a medication to lower your cholesterol. This is where most of this testing is important — in that middle block for borderline and intermediate patients. Those are the patients that we usually recommend get these other tests that we were talking about earlier. So we’re going to start going into each of these individually and talk about them a little bit more.

For me, when I see a patient that’s in that intermediate category, the first thing I look at — and if some of you are my patients, I may have asked you these questions — is do you have a family history of premature heart disease? Did your mother, father, or grandparents have a heart attack when they were less than 65? If they did, what kind of lifestyle did they have? Were they in that high risk category with high cholesterol plus smoking plus habits that kind of led to increasing heart disease like alcoholism or uncontrolled diabetes?

Other things I look at are your lab work — we look at your LDL and see if it’s constantly elevated over 160. Something about metabolic syndrome, meaning that if you have obesity paired with high blood pressure, paired with high cholesterol, paired with diabetes, then that type of patient is more likely to have heart disease as they grow older. Do you have kidney disease, defined as having an elevated creatinine, which is a clearance marker? Do you have other inflammatory conditions? Do you have lupus? Do you have rheumatoid arthritis? Those conditions will increase your risk of heart disease.

And also, do you have premature menopause? Being a female cardiologist, I see more female patients, so this is a question that I ask them and they’re like, “Why are you asking me? You’re a cardiologist.” The reason I ask is that when you have premature menopause, there’s a potential for you to have accelerated heart disease. The other thing that can be an accelerated risk factor is something called preeclampsia. That’s when female patients during their pregnancy have high blood pressure and have to deliver early, and that can also increase your risk of heart disease as you get older.

Certain high-risk ethnicities — our South Asian patients, for example — could be very trim, healthy, and live a good lifestyle, but something about their genetic code in certain populations of that area means they can have heart disease very prematurely. Is your triglyceride elevated? This is another marker that is akin to lipoprotein A. It’s called apoprotein B. And is that markedly elevated? That kind of factors into my assessment of how I take care of patients. And then sometimes, if you have vascular disease, that can also increase your likelihood of having heart disease.

So when I look at all of that information, I use my tools. The first one is called the calcium score — the coronary artery calcium score, or CAC. We’re going to refer to it as the CAC score throughout because as doctors we like to abbreviate things, but just so you understand if you see that in the presentation, that’s what that is.

It’s a dry scan, meaning you lay down on the CT scan table, go in, and the CT scan takes a quick snapshot of your heart and tells us about how much buildup you have. It directly sees plaque and gives us additional information beyond your cholesterol and blood pressure. There’s been a lot of evidence behind it, and a score of zero — which we’ll get into the classification here — can put you at really low risk. A study done over up to 16 years with almost 7,000 patients showed very low risk of having a heart event during that time period.

So what does that mean? Zero is good. It’s not like in school. If you have a score of zero, that means you have no deposits in your heart. This caveat is important for some patients — a calcium score of zero can be very reassuring, but if a physician or cardiologist has a very high suspicion of heart disease, we can’t just anchor on that, because in some populations, particularly women, we tend to have soft plaque. My patients always ask what that means, so being a foodie, I say the difference is basically flan versus crème brûlée. Crème brûlée is soft and kind of cottage cheese-like, but once you form a calcified plaque, it’s going to be more like crème brûlée where it has that crunchy layer on top. So that’s what we see when we do a calcium score — how much buildup or crunch you have on top of your artery.

A score of zero is good. Minimal calcifications means we’re going to discuss lifestyle changes — you need to exercise, make more lifestyle changes, eat better. If you have diabetes, for example, I would recommend a statin. If you have high blood pressure, I would recommend a statin. But if you just have a high calcium score and high cholesterol, then we can really maximize lifestyle changes before we introduce a statin. Over 300, or in most cases over 400, we would put you on a statin and an aspirin and then do additional testing for your heart.

The calcium score is really important because it can be an important predictor of how you do. Patients always ask me — and I think I have that at the end of my presentation — well, my score was zero or it was really low, how often should I do it? Five to ten years is probably sufficient. At that point you’re probably seeing a cardiologist so we can help guide that therapy. But if your score is already over 200, I would not recommend getting annual calcium scores because that’s just extra radiation, and radiation by itself can accelerate coronary buildup and heart disease.

When you’re over 300, we put you on something called a high-intensity statin. There are other cholesterol medications, but at this point you should definitely be seen by a cardiologist and you should definitely get more testing.

The next marker that we are monitoring now for patients to see if they’re at higher risk of heart disease is lipoprotein A, or LP little A. It’s a genetically driven marker — a type of bad cholesterol that is made in the liver. It’s a particle that floats in your blood and it’s really sticky. In general, things that are sticky mean that your blood cells, as they’re circulating around it, recognize it as foreign and start attacking it and forming clots. That’s how people get more plaque, more inflammation, and then clots — which is when a heart attack happens, when a clot or a piece of that plaque goes down the artery and people get these events.

But unlike regular cholesterol, there’s not much you can do about this from a lifestyle standpoint. Patients will sometimes get this tested by their doctor or order these panels through laboratories, and they’ll come to see me with these high numbers and say, “All right, I’m going to diet and exercise and drive this really down, doctor.” And I have to burst their bubble and say unfortunately that’s not possible, because this is made by your genes as much as your eye color is.

But if you have a very high marker, your lifetime risk of having heart disease is much higher. In laboratories, depending on where you live, it can be reported either in nanomoles per liter or milligrams per deciliter — it’s not a typo in the number, it just depends on which laboratory you go to. Most of our labs are in nanomoles per liter. The ones in milligrams per deciliter are more seen in the European literature. A score of greater than 125 is very high risk. At that point, if you have those labs, you should see a cardiologist and they can help navigate that number and decide what to do with it.

What can you do? Diet and exercise are always helpful and fantastic — your heart loves it, your body loves it — but it won’t do anything for this marker particularly. Other cholesterol medications are out there, like Zetia or niacin. Niacin is actually a B vitamin that in very high concentration has shown a small improvement in that. As a physician, I always want my patients to be healthy, so if a vitamin can reduce your numbers, why not? But it just hasn’t panned out to clinical benefit — even though patients took it and it came down, it was very marginal and didn’t have a huge effect. Plus, niacin has a lot of side effects. People get a lot of flushing and GI issues, so even if patients want to take it, they start and come back and say, “I’m never taking that drug again.”

The good news is there are tons of trials happening right now. There is a new RNA therapy that’s coming out that’s targeted for this. There is also a class of cholesterol medications that some of you may be on or may know people that are on — PCSK9 inhibitors, brand names Repatha or Praluent. They have shown some reduction. Lipoprotein apheresis is a very complex process — the best analogy I have for patients is basically dialysis to remove this protein out of your blood. We generally recommend that for people who are just so high risk, have had multiple cardiac events, and have very high numbers. But the good news is that as soon as probably the end of this year or beginning of next year, we may actually be able to prescribe some of these medications because they’re in phase three trials right now, which means they’re almost ready to get approved.

So what do I do when patients come in and they have a high lipoprotein A? We do a lot of education and I reassure them that plaque formation is a multi-platform formation in the cholesterol in the heart. I look at their other risk factors — if their diabetes is uncontrolled, I focus on that; if their LDL is really high, I lower that; if they’re smokers, I tell them to stop immediately; if their blood pressure is high, I try to control that. I try to hit the multi-headed monster in the other regions that I can hit it until I get treatment for the lipoprotein A. If my patient has a history of a heart attack or bypass, I am more likely to start adding these injectable cholesterol medicines to the regimen if they have a high lipoprotein A.

The last topic of blood work that I’m going to talk about today is high sensitivity CRP. CRP is a protein that’s made in your liver and it can be a response to elevated inflammation. The high sensitivity version detects low-grade inflammation that can cause a little vascular damage, a little buildup, and a little cascade of inflammation in your arteries.

What do we do as cardiologists when we see that number? We look at the range. If it’s less than one, you’re low risk — you don’t have a lot of background inflammation. If you’re over three, there’s probably some sort of inflammation happening. The guidelines tell us that when it’s over two, you should use that as a way to be more aggressive about reducing the patient’s risk. If it’s greater than 10, it’s almost always not heart related — the patient just had a vaccine, just got a cold, or has some other autoimmune condition like lupus or rheumatoid arthritis. Greater than 10 is usually not related to the heart.

The good news is that if you do have this, it’s something you can do something about. Reducing your weight is important — even losing 5% of your weight has been shown to lower hs-CRP. Exercise is very, very good for your heart — 150 minutes a week. When I tell my patients that, they say, “Doc, who’s going to have time to go to the gym and sweat bullets?” I say even 15 minutes of walking a day at a steady pace. They’ll say, “Well, I’m really active at my job.” I tell them that at a job you’re chronically stopping and going — you’re probably not constantly walking 15 to 20 minutes at a standard cadence. When you’re walking at a steady pace, your heart has to regulate your blood pressure very differently. It has to keep you upright. It has to feed your muscles. So that’s more important and key for your cardiovascular health.

Heart-healthy diet — my go-to diet for my patients is the Mediterranean diet. First of all, it’s delicious. But second, it’s been very well studied and validated to really reduce risk of heart disease. There are a lot of other diets out there that patients are using, like keto and paleo and all kinds of different things. Those diets have not been as validated, and keto in particular — there were actually some studies that came out showing that for a prolonged period of time it can put a lot of strain on your cardiovascular system, plus increase your cholesterol.

Smoking — I think everybody knows how impactful that is for your health. Nobody’s smoking because they don’t know the dangers of smoking. When they queried a bunch of cardiologists leaving the AHA conference, which is the largest conference we go to, unanimously every cardiologist said smoking was the one thing they would never do. It’s just such an unfortunate lack of awareness back when it was very popular, and now we’re also seeing some young people getting into it with vaping, which also has a lot of effects on the heart and the body.

Statins are very important in overall cardiovascular health. Rosuvastatin and atorvastatin are the best ones based on the large studies that we’ve done, and they help reduce your cholesterol. Heart disease is still the number one killer across the world, but the curve is now doing a slight dip — partially due to advances in medicine and highly affected by statins and their ability to reduce cholesterol.

There are other medications that are cholesterol-reducing as well. There’s ezetimibe — the brand name is Nexlizet — that also helps reduce hs-CRP. I usually use that for my patients that have had heart attacks. I see it come up a lot for patients because they see it on social media and ask me about it. I generally don’t use that for what we call primary prevention, meaning reducing your risk of a heart attack before one has occurred. Secondary is when you’ve already had a heart attack and I’ve done everything I can — that’s when I usually use it. It’s kind of my last go-to, not a first agent.

So how do these three tests basically give us what’s going on with your heart? The calcium score will tell us how much plaque you have. It’s partially genetic and partially your lifestyle, and you can slow down the progression with medications, exercise, and a lot of other things to help reduce your buildup. Lipoprotein A is inherited and genetic. There are some treatments coming out, but as of today there’s not a very strong way to modify that, and the recommendation is to check this once in all adults — over 40 is probably reasonable. When patients are under 40, I generally don’t test that unless the patient tells me multiple first-degree relatives have had heart disease, because sometimes an abnormal lab can create health anxiety and I don’t think it’s going to make that much of a difference unless the cholesterol is also high, the patient has diabetes, or the patient is a smoker. hs-CRP, like we talked about, is a marker of inflammation and you can modify it with lifestyle changes.

These tests are important and you can’t do these instead of what you normally do, but you can always discuss this with your doctor and see if you’re a candidate. They’ll give you their thoughts on it and you can decide if this is a good way to go about it.

Here are some questions that patients tell me they want to ask when they go back to their doctor.

For the calcium score: Do I need to get that based on my risk factors? If you get a calcium score, you should always ask what it showed and what that means for you going forward. Do I need to keep taking my statin or start a statin based on that? And when should I repeat this? If your score is zero and you’re in your 40s and you want to do another one when you’re 50, I think that makes sense. But if your score is already 100 when you’re 55, you don’t need to get a CT scan annually. Once you’re above 100, I would not recommend repeating it. At that point you should see a cardiologist and they should do other tests to see what’s going on. Annual calcium scores are not validated, and every 5 years even if the number is high is not validated. If it’s zero or less than 50, you could probably repeat it in 5 years.

For lipoprotein A: You can always ask, “Have you ever tested me for it?” Because sometimes doctors order labs and if it’s normal we may not tell the patients — we just say your labs looked fine. You can ask, and then say, “Well, I have a strong family history of heart disease. Should I check it?” And if it’s high, what should I do? If you’re interested in clinical trials and your numbers are high, we could put you in touch with the right people.

For hs-CRP: Should I start statins? If you check it, would it change your decision about how you manage my cholesterol? So let’s say you’re in your 50s, you’re a post-menopausal woman, your LDL is 120, and you and your doctor are wondering whether to start a statin — you can ask whether a calcium score, hs-CRP, or lipoprotein A would help inform that decision and work on reducing your risk.

The key takeaways from today’s talk: A calcium score of zero is very powerful. There’s lots of data behind it showing that your overall risk is low at that moment — it doesn’t mean you can’t accumulate more risk, but you can feel very reassured. Greater than 100, we generally recommend starting statin therapy. The fact that it directly visualizes plaque is very helpful.

I will say this about calcium scores, because some of you in the audience right now may have a calcium score over 100 and may be developing some concern. Not every calcium score translates to what we call intraluminal obstruction, meaning that if you have a high calcium score, you’re not always going to have a narrowed artery. You could have some rust in your pipes, but you don’t need to get anybody to go in there and clean out your pipes. Even if your score is high, as cardiologists we order tests to see how much flow you’re having past those blockages, and if the flow is good, then we would recommend working on your lifestyle and doing more preventative and proactive care to keep you at that level and not let it grow further.

For lipoprotein A, it’s a good idea to get that checked once in your lifetime when you’re over 45. If it’s greater than 75, your doctor will be more aggressive about treating your other risk factors until we get these medications on board. And if they have a good safety profile, then we’re going to start recommending that on top of your other therapies.

For high sensitivity CRP, greater than two can be high risk and you need to start some treatment. You can lower it with diet, exercise, and certain medications, and inflammation can really be a driver for future heart attacks even if you have lower or normal cholesterol.

These tests are important to complement each other. As a physician or provider, you take all of this and use it as different tools in your toolbox to help your patient. Ultimately our goal is to have you live longer, be healthy, and prevent whatever we can prevent. If we cannot reduce anybody’s risk of having a heart attack 100%, how can we get you really close to that? Some of these medications, treatments, and tests help us get there by being more informed, active, and proactive. I did put my references at the end for those who are interested in reading the supporting articles. Some of you may have an interest in diving deeper, and you’re welcome to do so. That’s all I have, and I’m happy to answer any questions. Thank you so much for everybody’s time.

That was amazing. Thank you. I feel like the landscape for testing for preventable cardiovascular disease and doing tests to work towards treating risk factors before they turn into heart disease has just expanded. I’m still learning when’s the best time to order these tests, and I really appreciate you giving a little bit of guidance. If people have questions, please drop them in the chat and we’ll do our best to get to them.

I have a couple of questions. If a patient has completely normal cholesterol — very very low risk LDL — and they’re maybe in their 40s or 50s, would you consider checking all of these tests, or how would you decide when to order them?

I usually look at the patient’s whole history. If they have low cholesterol but they’re pre-diabetic, they’re obese, and they say, “Oh, my aunt Sally died when she was 60 from a heart attack, and my uncle Joe had this, and my father had a stroke when he was 60” — a lot of those things trigger me to say, “Okay, well, maybe there’s something going on.” So that part of the history helps me decide.

I have not been ordering all of these for everyone, and I think that’s appropriate. For that particular patient, if they don’t have any symptoms, don’t have any of the other risk factors I showed you at the beginning — inflammatory conditions, none of that — and they’re otherwise healthy and active, you don’t have to do these. They’re not required as part of a standard assessment. But if you have somebody whose cholesterol is a little borderline, they’re not sure if they want to start a statin, and they’re not sure if they want to do anything different — then at that point you can add these to your toolkit to inform the patient about their risk. For the particular patient you mentioned, if they don’t have any other risks, I wouldn’t do it.

And as I asked that question, I realized you probably don’t see that person, right? I mean, you’re going to see them when their risk factors sort of add up and I’m concerned — that’s usually when I’m saying, “Hey Arzu, I need you to take a look at this.” But on your side, I would focus on making sure there are no alarm signs in their history, both personal and family. If that looks good and they don’t have any other risk factors, I guess you could do the lipoprotein A, but I think I would wait until there’s actual treatment for it, because there’s a lot of health anxiety that gets created with these numbers. It may not clinically manifest as heart disease, but because it’s high, patients get concerned and want to know, “Am I like a ticking time bomb?” I tell them it’s not like the BRCA gene — if you have it, you’re more likely to have breast cancer. With this, I tell them that if we cloned you without it, you would be lower risk, but it doesn’t mean you’re imminently heading toward a heart attack.

With the lipoprotein A — if that’s elevated, you’re saying we don’t really have good treatments at this point?

Yeah. We have some, like we talked about. If you have a person in this category and it’s elevated, you can do the PCSK9 inhibitors if they’re very high. The challenge I see is that if a patient doesn’t have a calcium score that’s really high, or insurance that covers the PCSK9s, even if I wanted to do it for lipoprotein A, the insurance would say no. But for direct treatment, no, we don’t have anything right now. So when it’s high, I focus on reducing their other risks and making sure I can reduce that. But like I said, if it’s a patient that already has a stent or a bypass, then I’m going to go more towards that.

Would a statin help at all? I know a statin doesn’t necessarily lower the lipoprotein A, but would it help?

The statins will help reduce your LDL, so they would reduce the inflammation and reduce that. I think if plaque was just from high LDL and this, we would put everybody on a statin and we’d all live forever. But it’s a complex field. We’re still learning every day — these medications have literally come out in the past 10 years, so things are very dynamic. Right now, statins don’t really do much in terms of reducing the lipoprotein A because again it’s a genetic protein and the statins are not targeted to affect it. But I have seen some of my patients clinically with the PCSK9 inhibitor where their lipoprotein A comes back lower — about 25% less than what it was. It’s not a substantial drop, but it does help.

Yeah, this is just emerging information that we’re trying to figure out how it correlates to the clinical picture and how to give good recommendations to patients. These PCSK9 inhibitors — and inclisiran, brand name Leqvio — are injectable cholesterol medications, and they’re actually also developing some oral treatments as well, because some patients are sensitive about injectables. I usually do a tutorial and have a sample injector in clinic — the needle is very, very small — but if they’re very averse to that, then unfortunately we don’t have any treatment for them.

There is a question in the chat from Linda. Linda wants to know about LDL/apoprotein B — if it is borderline, what can you do about it?

For borderline apoprotein B elevation, we don’t know as much about that. That marker is elevated and I kind of treat it the same way as lipoprotein A in terms of how aggressively I treat the LDL and how I treat the cholesterol. But it doesn’t have as much of a high vascular inflammation and cardiac effect as the lipoprotein A does. So it’s not as alarming, but it does show some elevation.

And apoprotein B can be reduced — I’ve seen apoprotein B levels go down when you treat with a statin too.

Correct. Yes. That one’s a little bit different from lipoprotein A. That one is more modifiable. I kind of think of it as telling us how bad the LDL is behaving. So if that level’s a little bit higher and your LDL is a little bit borderline, I’d say your LDL may not be extremely high, but you’re probably at higher risk for that LDL to lead to an event. So I might be more likely to consider starting a statin medication if I see that.

Yeah, I think that’s a good plan and that really helps patients reduce that.

There’s a question: “When it comes to cardio health, can you address strength training versus cardio?”

I love both. There are a lot of new ways to exercise. People are doing a lot of HIIT and Orange Theory and I think that’s great. High-intensity cardio training is good for your heart, but that shouldn’t be the primary way you exercise. Strength training is really good for your overall health, and your heart loves it too. Your heart doesn’t like to always go 100 miles a minute. I think both are excellent, but I would focus more on strength training and low-level, not high-intensity cardio exercise. Especially as people get older, it’s more difficult to manage that.

There’s another question — it looks like it may be from Randy. “My wife and I both had EBT heart scans back in 2000. Her score was low. I had a moderate score and was put on a statin. Since then, I’ve kept my cholesterol low and maintained a healthy weight. Should I repeat a CT scan now?” Randy says he’s 67.

Thank you for that question. EBT scans were what they were calling the tests that the lifeline screens were doing — something that was very popular back then. For Randy and Mrs. Randy, I think at this point it’s been 25 years and you’ve probably accrued some calcium. We start laying plaque in our arteries as early as our 30s, so you had some back 25 years ago when you were probably in your early 40s. I think if you’ve been on a statin and your numbers are good, I would focus on maybe getting an EKG with your primary care doctor, having them do a good history and physical, and if your cholesterol is well and you haven’t had a stress test, it’s probably not a bad idea to do a stress test to see how that calcium has developed over the years. Instead of doing another calcium score, I would recommend a stress test, because we know you have plaque — now I need to know how high risk it is. A stress test helps me figure out the risk of that plaque and whether it’s grown over the years or been relatively stable.

So I have a question. The way that statins actually work — correct me if I’m wrong — is that they stabilize plaque in our coronary arteries. So the soft, gooey plaque is the stuff that’s unstable, and the crème brûlée type of plaque is the stuff that’s a little bit more stable. What’s happening with the statins is that they kind of calcify the plaque a little bit. So the coronary calcium score could potentially go up a little once you start a statin.

That’s why I say once it’s high and you’re on a statin, just don’t recheck it. Patients always come back and say, “See, statins are bad for me — now I have more calcium in my heart.” The reason is that the statin will kind of put a protective shelf over that plaque so it helps prevent it from coming out and causing a heart attack. It doesn’t mean that the diameter of your artery is shrinking. It means that if you had this much plaque, it’s just covering it up really tight so you don’t have an injection of that plaque into your bloodstream. So that’s how statins help — they reduce the circulating amount of cholesterol so you don’t build more, and they also stabilize what’s built by putting a protective film or shelf on top of it so it doesn’t come out into the bloodstream.

And to be honest, I don’t order the high sensitivity CRP that much, but now I’m starting to think about incorporating that a little bit more. Is that reasonable?

I think if you’re thinking about ordering a lipoprotein A, you should put in an hs-CRP. That’s how I do it. Those two kind of run together. Because one can kind of help you with the other. If everything is high, then you know that they need to get risk stratified and see someone, and if everything’s okay, then you can reassure your patient.

Does anybody have any other questions? Maybe about statins or any of the medications we’ve talked about?

Now, a reason that I like these tests is just because it’s more than just your LDL at this point. For the longest time we just had the cholesterol panels and it told us part of the story but not the whole story. We’re also kind of shying away more and more from the idea that if your good cholesterol is really high but your bad cholesterol is not great, it balances out. The previous school of thought was that if your HDL — your good cholesterol, or as I call it, the happy cholesterol — is high, then you can give the patient a little discount on their LDL. But we’re learning that very high LDLs over 80 can be bad for your heart, and also very high HDL over 80 can be bad for your heart. If you have a high LDL above a certain number, it doesn’t matter what your HDL is because your risk is going to be high for developing plaque. Usually I try to investigate a little bit more with those patients if they’re not interested in taking medications.

Unless there are any other questions, let’s start wrapping up. Oh, here’s a comment — it looks like it may be from Randy or Lilia. “My most recent LDL was 106. What’s best to lower this?” Randy, I think you said you were already on a statin. The other question would be what is the dose of the statin that you’re on, because that’s one way to lower your LDL. And if it’s the wife who had a low score but wasn’t on a statin, then she should probably be on a statin.

So depending on how low your EBT score was 26 years ago — if it was less than around 50 — then you should probably repeat that. If you’re not on a statin and your score has gone high, then your doctor may increase your dose and adjust your medication that way. But since your score was normal way back in the day for your EBT score, you could start off with a calcium score and from there decide if you need to be on a statin.

Linda’s back. She’s asking about having a high HDL — she says her HDL has always been around 110. Should she be concerned? And she did have a coronary calcium score of zero.

It’s kind of hard to risk assess in a bubble, but I think if the HDL is high, and your calcium score is zero and your LDL is okay, then I would look at seeing if there’s anything in your diet or lifestyle that can increase your HDL. One is if you’re taking too much omega-3, that can raise your HDL. If you’re taking some supplements that people have been advised to take for cholesterol, that can incorrectly increase your HDL. If you have more than one alcoholic beverage a day, that can also increase your HDL. If that’s not the case, and your calcium score is zero and everything else is okay and you’re not diabetic, then that’s just something that could be trended in your case because it’s probably genetic — that’s just how your body’s processing cholesterol.

That’s actually a really good use of the coronary calcium score. You’ve got a question, maybe a borderline reading, and you can actually take a look at the coronary arteries and see if this is something you need to act upon. There’s the power of that additional testing — instead of just assessing risk on paper, you can see it directly.

Absolutely. And I tell my patients that when your physician orders a test, they should have a plan of action for the results. Sometimes patients get tested, we get a number, and then they’re like, “I don’t know what to do — go see a cardiologist.” So if they’re ordering it, there should be some thought behind it. If it’s not going to change how I manage you, I don’t think it’s necessary to order it. We sometimes over-test patients, unfortunately, and it creates unnecessary anxiety.

I use the analogy of throwing the kitchen sink at a situation — it’s not helpful. Tests have to be thoughtfully ordered in order to give appropriate information that we can actually interpret and then advise upon.

Brian has a question about the significance of LDL particle size.

Mr. Folkertz is very up to date. I didn’t put that in there because that’s a whole extra 10 to 15 minutes of discussion, but the cliff notes version is that we’re getting really fancy and can now see how big, medium, or large your particles of cholesterol are. The best way I tell my patients is the bigger the LDL particle, the harder a time it has burrowing under your artery and making plaque. The smaller it is, the more likely it’s able to do that. So the particle size helps us sometimes categorize the LDL and be more aggressive about treatment.

I perform this type of testing on patients who have some hesitancy about treatment — they usually say, “I’m not resistant to treatment, but I don’t really want to start something unless I really, really have to.” So I order these tests plus what’s called a fractionation of your LDL. That way I can say, “Listen, this is your risk — you’re meeting all the high-risk check marks. I really think we should start reducing your LDL with some sort of medication.” That’s how I use the LDL particle size to help me.

And there’s also LDL type A and type B — it’s kind of a different flavor. I pay attention more to the size than the type, because there are high-risk types and low-risk types.

Great questions tonight. I was telling Dr. Habert I had to really be prepared — I feel like some of the patients that joined this town hall already have a lot of knowledge and I wanted to make sure I put some solid medical evidence in there.

Last chance for questions. We’ve got some thank yous, which is nice. Thank you everybody. I really appreciate you all staying on and I hope this was helpful. You guys ever need anything, we’re here to help.

I’ll get some appointments on my schedule to discuss cholesterol, and Dr. Jangiri can be my partner in crime as we sort of figure this out and try to reduce everybody’s risk so we can avoid those heart attacks and strokes.

We are going to wrap things up. Once again, thank you Dr. Jangiri, and thank you to everyone who joined. I love doing these town halls — I learn so much myself and I’m just so grateful that people would take time out of their night to join us. Have a wonderful evening everybody and hope to see you all soon. Thank you. Good night.