Category: Hyperlipidemia

Categories
Heart Attacks Heart Health Hyperlipidemia

How To Lower ApoB Levels

We discussed the importance of measuring apoB levels to understand someone’s Heart Disease risk. Now, let’s talk about what we can do to lower apoB and by how much.

Diet: 5-10%

For most of us, reducing saturated fat intake and excess processed carbs could have an additive effect on lowering apoB levels.

Increasing fiber intake and switching to more whole plant-based foods with the occasional healthier oil options will further lower apoB levels.

Some clients believe that saturated fat can be good and cite research that it may not be as harmful as some claim. Our Heart Health Coaching Program settles this debate through lab tests by monitoring not only apoB levels but also inflammatory markers.

Exercise: 7%

Some studies show that exercising 30 minutes 5 times weekly can lower apoB levels. Most of these studies focus on aerobic exercise and less on resistance training.

At HHC, we believe that resistance training can be incredibly potent when done properly and long enough.

Insulin Resistance: 10-15%

The factors that improve insulin sensitivity and, therefore, lower insulin resistance are often the same things as above – dietary change and exercise.

However, there are independent factors that make insulin more sensitive in the body that involve VLDL production. Or perhaps it’s all related and difficult to tease out in studies.

Weight Loss: 10-20%

Some individuals have apoB production/clearance pathways incredibly sensitive to weight. Losing weight helps improve apoB by as much as 20%.

Stress Reduction: 5%

Stress is part of everyday life. It’s the type we cannot cope with that is the most damaging. There are plenty of proven coping strategies out there, as well as medication techniques.

8 weeks of meditation could lower apoB levels by up to 5%.

Sleep Improvement: 10%

When it comes to sleep, we care about restful sleep. Any number like “7-8” hours is often too vague. Some of our patients need 9-10, while others can go a few days with 6-7, and they can recover with more sleep later.

It’s rare to see someone who does well when consistently getting too little sleep. When their sleep is improved, we see apoB lowering by 10%.

Want to Lower Your ApoB?

Work with Coach Mo – he’s caring, competent, and curious. Come up with a strategy to lower your apoB and improve your Heart Health.

Book Today
Categories
Heart Attacks Heart Health Hyperlipidemia Statins

apoB and Cardiovascular Disease

Most clients in our Heart Health practice show up with their lipid profile in hand, most concerned about their LDL and HDL numbers. In this article, we’ll share our viewpoint on apoB and cardiovascular disease risk.

Old, Discarded Viewpoints

Lipidologists and preventative cardiologists no longer rely on LDL-C as a way to risk stratify someone for heart disease.

In most laboratories, LDL-C is often calculated and rarely measured directly, making LDL-C an even less reliable marker for cardiovascular disease risk.

Once believed to be protective, HDL-C is no longer believed to serve much value when assessing a lipid profile.

Modern Lipid Profile Analysis

If you have one of your old lipid profiles lying around, you can calculate your non-HDL cholesterol, which, 97% of the time, corresponds to apoB levels.

(Total cholesterol) – (HDL cholesterol) = non-HDL cholesterol

You can also use an online calculator.

Triglyceride Levels

these days, we mostly use triglyceride levels to determine if somebody’s dietary intake of simple carbohydrates is excessive.

The higher triglycerides are, or the more insulin resistance somebody is, the more likely they will have excess cholesterol needing transportation by apoB lipoproteins.

apoB Targets

apoB can be cheaply measured ($20 – $60) in most laboratories. Insurance often covers it, but that’s hardly necessary for lab testing.

The way we determine apoB targets is to determine a person’s overall cardiovascular disease risk.

1. Very High Risk

Those at very high risk should have apoB levels below 60 mg/dl.

If apoB isn’t available, their non-HDL-C should be < 90 mg/dl.

From the old LDL-C understanding, the goal would be an LDL-C below 70 mg/dl.

2. High Risk

Those at high risk should have the following numbers with a little more wiggle room compared to someone who is at very high risk:

  • apoB < 75 mg/dl
  • non-HDL-C < 120 mg/dl
  • LDL-C < 100 mg/dl

ApoB and Cardiovascular Disease

The biggest drivers of Atherosclerotic Cardiovascular disease (ASCVD), sometimes also referred to as cardiovascular disease (CVD) are the following:

  • tobacco use
  • hypertension
  • elevated apoB
  • elevated Lp(a)
  • elevated fasting insulin levels

How to Lower apoB

It’s hard to know who responds to what treatment. Some may not be able to tolerate statins even though their apoB drops drastically.

Others may see a massive drop in apoB by changing their diet, especially if they are hyperabsorbers of cholesterol.

Just as we have hyperabsorbers, those whose intestines squeeze every last bit of cholesterol from the food, we have hyperproducers.

The hyperproducers produce a lot of cholesterol from the liver, which finds its way into the circulation, causing elevation of apoB.

These changes partly explain why some will respond well to statins and even better when we add ezetimibe.

Repeat Testing of apoB Lipoproteins

In general, we advise our clients to check their apoB levels annually. As soon as it starts to get out of range, we discuss various interventions.

build a chance of a sudden rise in this lipoprotein level is low, regular monitoring will allow for immediate intervention.

apoB Lowering Through Exercise

When it comes to lowering certain risk factors, blood pressure is quite amenable to lifestyle changes.

It does not seem to be the same case with apoB levels. For those with a high elevation of this molecule, it is always advisable to start with lifestyle modifications first.

And certainly, there are certain dietary changes, such as a very low-fat diet, that can greatly improve someone’s apoB levels. Unfortunately, this is rarely reachable.

Categories
Heart Health Hyperlipidemia Statins Treatment

Reversing Atherosclerosis

Is it possible to reverse atherosclerosis in the coronary arteries or anywhere else in the body? This topic, often called plaque regression, deserves an overview for anyone considering any Heart Health intervention.

Atherosclerosis – The Approach

It’s fair to say that if you are past your teenage years, you will have some atherosclerosis. This is the plaque buildup inside the arteries of the body which causes health problems mostly when it affects the blood supply to the heart, brain, and limbs.

1. Main Approach – Prevention

The main approach to atherosclerosis is preventing it.

With our Heart Health Coaching, the goal is to live a lifestyle that:

  • decreases blood pressure
  • lowers circulating apoB levels
  • decreases inflammation
  • improves mitochondrial health

For many, lifestyle changes are adequate, and we can track serum biomarkers such as lipid levels, inflammatory markers, and serum insulin levels to track success.

For others, chemical interventions may be necessary, even for the prevention stage, such as statins, ezetimibe, or the PCSK9 inhibitor class of medications.

2. Secondary Approach – Treatment

Some clients will already have an atherosclerosis diagnosis. Perhaps a physician noted it on a knee X-ray, or the patient is experiencing symptoms of angina.

The secondary approach is to help prevent major cardiovascular events (heart attack, strokes, peripheral vascular disease) due to the buildup of this plaque.

Must we reverse atherosclerosis for this secondary approach to be successful?

Plaque Regression

Western Medicine states that not all plaque is equal. We have stable plaque and potentially unstable plaque. Though this is a rough categorization, it’s a helpful mental model to follow.

The goal is to minimize unstable plaque but encourage remodeling of existing unstable plaque and perhaps to encourage plaque regression.

In plaque regression, the amount of plaque actually decreases. Tiny intravascular ultrasound (IVUS) or a CT angiogram (CCTA) can confirm this.

Available studies show that high-intensity statin therapy decreases overall plaque volume by 10%, but that may not fully explain the decreased risk of cardiovascular events. So, perhaps stabilization is just as important.

Stabilization vs. Regression

This summary article determines which is better, stabilization vs. regression of plaque. Of course, in real life, we don’t have to choose one or the other – that’s the headache best left for the researchers.

1. Stabilizing Plaque

MIRACL, PACT, CURE, HOPE, and Lyon support the idea that plaque stabilization is effective.

We know from various studies that a lower-fat diet, increased activity, and managing stress/sleep can stabilize plaque, shifting more toward the preferred calcified plaque.

It’s important to mention that statins tend to change plaque composition toward:

  • fibrous volume
  • calcified plaque
  • reduction in fibrofatty volume
  • decreased a necrotic core

2. Reversing Plaque

ASTEROID, REVERSAL, and SATURN studies, on the other hand, focused on plaque reversal as a way to decrease the risk of cardiovascular disease.

We haven’t come across any convincing studies to demonstrate that plaque regression is necessary to help prevent major cardiovascular events.

However, if plaque regression is the goal, high-dose statin treatment should be the treatment of choice.

This answers the common questions our clients ask us about whether to repeat CT angiograms or CACs.

Categories
Heart Health Hyperlipidemia Treatment

Should We Be Testing for Lp(a)?

No doubt those with elevated Lp(a) have a higher risk of ASCVD, but the question is whether testing for Lp(a) is beneficial if we don’t have effective therapies for lowering it.

Lipoprotein (a)

It isn’t the best nomenclature, but this word refers to a low-density lipoprotein containing a particular molecule called apolipoprotein(a) or Apo(a).

The blood levels of Lp(a) are affected by a few factors, one of which, of course, is the LPA gene that encodes this molecule. Dietary habits, age, or sex doesn’t seem to affect your Lp(a) values.

It’s important to check for Lp(a) in the same lab for monitoring levels, but it may not be the best way to work with this lab value. Most experts will check this once or twice in the patient’s lifetime because it’s meant to indicate overall risk.

Lp(a) is made up of a liporptein plus apoB and Apo(a). The Apo(a) portion can independently elevate the risk for clotting.

Lp(a) & Disease Association

We know from observational studies that those who walk around with higher Lp(a) levels tend to have a higher risk of ASCVD, coronary heart disease (CHD), cerebrovascular disease (CVD), and aortic stenosis.

This molecule is also an acute phase reactant, so those with inflammation will have higher values. Meaning also it shouldn’t be checked during times of inflammation.

From a UK study of half a million individuals, we know that for levels above 20 nmol/L, there was an increased association with ASCVD. Which translates to a 10% higher risk for each 50 nmol/L increment above this value.

Lowering Lp(a)

Unlike someone’s LDL values, we don’t have good tools to lower a patient’s Lp(a). At least, that’s the current widespread consensus. Some experts believe there are treatments (medications) in the pipeline that will lower the serum level of Lp(a) but as much as 80%.

The next question is whether lowering Lp(a) levels would change someone’s health outcome.

With HDL and homocysteine levels, we have seen that changing the value of these in the blood through directly targeted medications doesn’t have an actual cardiovascular disease outcome.

So, we’ll see if medications that lower Lp(a) will change a person’s ASCVD. Some of the upcoming clinical research should reveal that.

How To Treat Elevated Lp(a)

Some countries, such as the UK, regularly test their patients for Lp(a). But all countries are still waiting for final results to determine which Lp(a) lowering treatments will lower the risk of atherosclerotic heart disease.

It’s important to recognize that statin therapy can sometimes elevate Lp(a). Again, this is the tough part of understanding the complicated interplay between the different key players in heart disease.

Fortunately, despite the rise in Lp(a) caused by statins, those at risk will still benefit from statin’s independent anti-inflammatory and LDL lower effects.

1. PCSK9 Inhibitor

Though PCSK9 inhibitors seem to lower Lp(a) values, it’s unclear whether they can lower the risk of heart attacks in those with high Lp(a) values.

2. Lipoprotein Apheresis

Similar to dialysis, though not as severe, this can be used weekly to lower Lp(a) values by 70% or more.

3. Antisense Therapies

Some antisense oligonucleotide treatments are being researched to lower patients’ Lp(a) levels.

4. Inclisiran

Leqvio is a medication for those with elevated ASCVD disease risk who may not be candidates for standard treatment alone.

This molecule works in the synthesis pathway of the PCSK9 protein.

Serum Lp(a) Values

Serum values above 165 nmol/L seem to be associated with the highest risk, such as coronary heart disease death, heart attack, or needing immediate vascular intervention.

Some believe values above 125 nmol/L equate to elevated risk; other experts set that bar at 50 nmol/L. The patient’s clinical history obviously matters a lot.

Categories
Diet Heart Health Hyperlipidemia Prevention Statins Treatment

How the Body Regulates Cholesterol

In this article, I wanted to provide a basic overview of cholesterol regulation in the body. I share such articles with my heart health coaching clients whenever necessary. How the body regulates cholesterol is relevant to choose the right method of controlling cholesterol levels.

Cholesterol Regulation

Cholesterol is quite essential. The following key players regulate cholesterol in the body:

  • cells lining the intestine
  • liver
  • pancreas
  • intestinal bacteria

The food we eat has some form of cholesterol which becomes absorbable after manipulation by intestinal bacteria and pancreatic enzymes.

Cholesterol can enter the bloodstream also through the bile system. Whether you still have a gallbladder or not, your liver will produce cholesterol pumped into the intestines.

Cholesterol Absorption Varies

Some individuals are hypoabsorbers of cholesterol. No matter how much high cholesterol foods they consume, their intestinal cells don’t take up much of it.

Others are hyperabsorbers of cholesterol; even the lightest meals can have every bit of its cholesterol extracted and pumped into the bloodstream.

Cholesterol Regulation and Treatment Options

For my hypoabsorber clients, I am less concerned about their dietary cholesterol intake. Their cholesterol production in the liver would be a more important factor.

The hyperabsorbers will benefit a lot from a particular dietary change. Sometimes it helps to cut back on saturated fats, but eating times and gut bacteria are also important criteria.

Dietary change? Statin therapy? Ezetimibe? Evolocumab?

To answer that, I need more information about the person. A generic cholesterol test won’t always tell us the whole story.

The Liver’s Cholesterol Production

How cholesterol is regulated in the body has a lot to do with the liver. This fleshy organ on the right upper quadrant of the abdomen produces LDL, HDL, and VLDL particles.

Statin drugs decrease the production of cholesterol molecules in the liver.

The liver also has LDL receptors and absorbs cholesterol.

From fatty liver to elevation of liver enzymes to problems with the gallbladder, it’s important to consider the health of this organ when assessing my clients.

The Role of Gut Flora and How Cholesterol is Regulated

Some bacteria in the gut convert free cholesterol molecules into a stanol chemical that intestinal cells cannot absorb.

We could call these beneficial bacteria. They can help slow down the absorption of cholesterol for certain individuals.

Ezetimibe is a medication that works similarly, blocking the absorption of free cholesterol molecules.

Categories
Heart Health Hyperlipidemia Statins

Do Statins Prevent Heart Attacks?

For the right patient, a statin is a lifesaver. But do statins prevent heart attacks? They are used to lower cholesterol levels, but some will still suffer a heart attack even when taking a statin.

It’s essential to understand this concept. You can still suffer a stroke or a heart attack while taking a statin medication.

Primary & Secondary Prevention

Statins are a group of medications such as simvastatin and atorvastatin. There are others, and each has its place in managing serum lipids.

A statin is prescribed to some patients to lower their cholesterol and prevent a heart attack, stroke, or other atherosclerosis-related medical conditions.

This primary prevention strategy is used for those who haven’t yet had a heart attack or stroke. But many will have had such cardiovascular events and be put on a statin – we refer to this as secondary prevention.

Secondary prevention means trying to prevent a second or third heart attack or stroke.

Statins and Heart Attacks

Western medicine’s big gun remains the statin drug. Even with this, nearly 25% of those on a statin still can suffer a heart attack.

I fished this number from a few studies and my personal experience with my patients. Now that even more patients are on statins, this number likely is higher.

Heart disease is a complicated process. Simply lowering your cholesterol isn’t enough to entirely prevent a heart attack. It’s a big step in the right direction – for some.

Preventing a Heart Attack

A statin won’t prevent a heart attack. It will lower a person’s cholesterol. This lower serum lipid profile may slow the progression of atherosclerosis.

A heart attack can happen in those with normal cholesterol levels. This is why it’s essential to address heart health not just from the serum lipid perspective but from a broader angle.

Whether you’ve already had a heart attack or are trying to prevent one in the first place, it’s crucial to figure out what your risk factors are.

Some of us can easily change our diets, and others will have a hard time with diet but can readily improve their exercise capacity. You’ll significantly improve heart health regardless of which strings you pull on.