* ApoB - about 20% of people with normal cholesterol results will have abnormal ApoB, and be at risk of heart disease.

* Lp(a) - the strongest hereditary risk factor for heart disease.

* hs-CRP - inflammation roughly doubles your risk of heart disease

* HbA1c - insulin resistance is a risk factor for just about everything.

* eGFR - estimates the volume of liquid your kidneys can filter, and is an input to the latest heart disease risk models (PREVENT).

Easy to order online: https://www.empirical.health/product/comprehensive-health-pa...

CAC is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.

Some of the tests you list (like A1C) are baseline things everyone should get checked every year. Agreed that the others could provide value for those who want to know more about their risk level; however, it’s uncommon for those tests to turn up positives without one of the baselines having already raised at least a yellow flag.

None of the tests you listed will tell you whether you have any soft plaque buildup. They just tell you more about your risk factors. However, there are ultrasound tests that can detect increased blood pressure in major arteries, which IIRC does reflect soft plaque buildup.

I'm prescribed a baby aspirin for the Lp(a). The AHA no longer recommends baby aspirin to the general population but 218 takes me out of the general population. The thinking is that Lp(a) clots and baby aspirin counteracts that.

It's only the CAC score that provided me with peace of mind that I didn't need to reach for statins.

The way I view this is that, if you can get more information, why wouldn't you? Cost of course, and I understand why insurance might not cover the procedure, but anybody of a certain age with any risk factors who is in a position to afford it benefits from doing so.

This is why there are tests which previously were recommended to a wide range of people on a regular basis which are now only recommended in more limited settings. PSA is a good example of this.

The question to ask is, is doing this test likely to improve my life, or not? And while you probably can’t know the answer for a specific test in your specific case without trying, you can often know the probability that it will improve your life based on statistical analysis of other people who have gotten that test and how it went for them.

Using CAC store to gauge risk is like waiting until you have end stage symptoms of any disease before you consider yourself at risk. The ship has already sailed and you should have instead focused on prevention for decades.

The sibling comment is a great example of the misinformation here. They have high cholesterol but a CAC score of zero gave them the peace of mind to not use statins.

eGFR is typically inferred from serum creatinine (not creatine!), which is part of both a comprehensive and basic metabolic panel (CMP/BMP), which your GP usually orders, along with a CBC, and perhaps an HbA1c.

You could theoretically increase SFA to target Lp(a) while still using lipid-altering drugs to target LDL.

https://my.clevelandclinic.org/health/drugs/22550-pcsk9-inhi...

Outside of that, if your Lp(a) is high, then the first strategy would be to choose a lower ApoB target than you would otherwise. (Every Lp(a) particle is also an ApoB/cholesterol particle, but 6x more atherogenic. So by lowering ApoB, you are compensating for the effect of high Lp(a))

Summary of the current research/evidence is here: https://www.empirical.health/blog/lipoprotein-a-blood-test/#...

https://x.com/gregmushen/status/1917780163242385586

And another guy lowering his with Amla, lysine and vitamin C

https://x.com/gregmushen/status/1924660722786828584

In the UK we have the NHS and, although private healthcare is available, the NHS are gatekeepers with long waiting lists to see the doctor.

In UK culture you are just not going to 'waste NHS time' by asking for the tests that could inform you on what lifestyle choices you might need to make in order to head off chronic non-communicable diseases. You have to get a chronic disease, then the doctor will interpret the test results and not let you know what the numbers are, just what medication to take, optionally with lifestyle changes.

As a consequence, nobody in the UK knows what their cholesterol levels and whatnot are, yet, in the USA, plenty of people know these numbers.

Do healthcare providers actively upsell testing in the USA?

In my experience, normal doctors do not, but there are a lot of private businesses that make their living selling testing.

Also, consider that despite a lot of people knowing their levels in the US through testing availability, health outcomes are not better. So, we know more, but don't do anything about it. I don't know what's worse.

Out of the approx. 250 million adult americans, a large cross section do manage their health.

While average outcome might be better in the UK, it's useless to lump the 60% (150 million) of americans who are not obese in with the 40% (100 million) who are obese. And while this is easily the most major, it is just one measure of health.

That a lot of couples like to share the same chair??

However, chairs get left outside and they can rot. This can lead to collapse even if a 50Kg person gets on. This can be incredibly dangerous. Hence every chair should have a secondary support structure, in some cases this can be wire under tension, other times it might have to be steel tubing.

There are thousands of chair designs, none of them built for the ultimate eventuality of catastrophic failure.

Load ratings near the failure point are only done when the failure will not cause a problem, or when the failure is actually a desirable property (breakaway tethers of various types.)

So over about two months I switched to an informal low-carb diet. e.g. I stopped drinking milk, I ate Carl's Jr. six-dollar burgers as lettuce wraps for lunch, and sometimes just roast beef and mayo.

Over three months I lost something like 30 pounds, hitting a body fat percentage around 12% -- this wasn't the goal, but FWIW.

My HDL before was 17, after those three months, 25.

Then I added in various forms of exercise and got it up to about 55.

I've since engaged in various diets, and levels of exercise -- although I've never gone back to the original diet where whole meals consisted of a quart of ovaltine. My HDL has never dropped below 40, nor been higher than 65.

They're also available from most community pharmacies (again free of charge for at-risk patients, but for everyone else it should be about £10 for a simple finger-prick test or £30-50 for a full lipid profile).

By community pharmacy, does that include a typical Boots the Chemist?

Healthcare is very different in America and I am not seeing the benefits of yearly 'bloodwork', it must be an upsell so they can get people onto statins and whatnot for life.

Catch the elevated A1c before it does any damage, or get diagnosed from a hypoglycemic episode?? (By which point a lot of damage has been done.)

Catch the elevated TSH and supplement before there are any symptoms, or wait until the patient presents with hypothyroid? Note that the patient will have been through a fair amount of blah before the diagnosis is made. And thyroid hormones are very dose sensitive and it's a couple of months to stabilize on a new dose, so bringing the patient back to normal can take quite a while. US approach, my wife's TSH was high, they put her on some thyroid hormone, no symptoms of hypothyroid and no rush to dial in the dose because it's still within the body's ability to compensate and thus causes no problem.

And the subject of this thread, statins. Again, much, much better caught before it does damage.

The current guidelines for prescribing statins are based on your risk of a major cardiac event in the next 10 years (forecasted using a statistical model). But given that plaque builds up in your arteries over your lifetime, there's a strong argument for using a 30-year or lifelong time horizon.

The rate of serious side effects is quite low (e.g. brain fog), but the reported rate for muscle weakness is non-trivial.

FWIW, similar bundles I've seen online are priced at $400-$500.

All 85 biomarkers, if purchased separately, would cost a total of $1,490. ApoB, for example, usually costs $60 if done in isolation, Lp(a) is $45, hs-CRP is $65 at Quest, etc. The bundles end up having lower pricing due to volume discounts and being able to amortize some of the cost across biomarkers.

I believe eGFR (via creatinine testing) and sometimes HbA1c (if diabetes screening is ordered) are the only things listed may be part of a routine health check from a common/inexpensive blood test.

about: Data for good. Co-Founder at Empirical Health (https://empirical.health).

Before: Risk Engineering at Brex

No "share" or "download" button in the app? Sure, "apps are cool" and all that - but what about folks who want to archive or share their health data? AFAIK literally no provision to share all those nifty biomarkers with my doctor (except many, many screenshots)?

Nowhere in the "how to get blood test" email instructions does it bother to mention a urine sample will also be needed. Kinda useful to know if you should not pee right before heading to the lab.

(coronary artery calcium testing)

These tests don’t have perfect accuracy and resolution, so low or zero results don’t mean that a lifetime of high cholesterol won’t catch up with someone in their 60s and 70s, yet a lot of podcasters and social media influencers are making those claims.

A ketogenic diet is 70% fat.

It’s literally impossible to get into keto with a diet of leafy greens and salmon. You would have to augment with a lot of fat from some other source and also limit salmon intake to avoid consuming too much protein. Salmon has too much protein and not enough fat to even come close to keto ratios.

You must be thinking of a different diet. A lot of people think keto is another word for low carb, but a real keto diet is very low carb and low protein.

If you do try keto again, bacon and such are the worst way to do it. Getting your fat content from a monounsaturated source like avocado oil can be helpful. Taking statins is also a good idea.

https://cholesterolcode.com/

There’s a good talk as well that presents this information in a very accessible way:

https://youtu.be/jZu52duIqno?si=NCEf4UGtgHG9sBOP

Nowadays I am convinced that what happened was completely explainable by the Lipid Energy Model [0]. Five days a week I was doing 60~90 minutes of cardio in the morning after skipping breakfast. Exercising in a fasted state while on a low carb diet meant that I had very low glycogen in my muscles and liver, which meant that the muscles had to mobilize fat as an alternative source of energy. Since fat is not water soluble, transporting fat through the blood stream requires packaging it inside a micelle wrapped in phospholipids -- a lipoprotein. Hence the elevated LDL & apoB.

The solution is simple: consume some carbs before and/or during exercise, and learn about the translocation of GLUT4 receptors if you are concerned about hyperinsulinemia.

[0] https://pmc.ncbi.nlm.nih.gov/articles/PMC9147253/

The other problem is that they’re picking and choosing which tests to believe and which to ignore.

They disregard their cholesterol tests because they don’t like the results, but embrace one or two CAC tests because they do like the results (when they’re young).

However the CAC results are a lagging indicator of cumulative damage that has been done. Cholesterol tests are correlated with the rate of damage occurring.

So embracing CAC and using it to justify ignoring LDL and others is the problem.

The downside, of course, is that once the damage is done, it's done, so it's a risk. (And as you said, they won't see the damage in their 20s.)

Imagine claiming "my diet is great, i got 0% on my calcium score" when that just means you have the same score as 95%+ of people at age 40.

By 55, 25% of people start showing some % of calcium and at 65, 75% of people have a reading on calcium score.

So anyone under 45 being proud of a zero score is just silly.

Also, taking a statin can increase the CAC score because statins cause fat build ups to calcify faster which makes them less likely to break free and cause big problems.

If you’re old: Great! Keep an eye on cholesterol.

CAC is a lagging indicator. Its usefulness is more about assessing damage done, not rate of change or future risk.

Can this plaque be reversed?

https://medicalxpress.com/news/2023-11-manganese-bullet-card...

It it also the backbone of apolipoprotein, which is the actual thing your Doctor is talking about when they say "good cholesterol" and "bad cholesterol". Apo combined with other things (triglycerides and phospholipids) make HDL, LDL, and other familiar "cholesterol particles".

Since they shuttle fatty acids around, these fatty acids can be oxidized. When there are too many lipoprotein particles than your cells can safely clear, macrophages end up being targeted by the particles. Macrophages that take on too many damaged particles (damaged by the fatty acid oxidizing) can ram into arterial walls, which summons platelets to try to fix it.

The platelets use a calcium-based substance to fix the damage. Its sorta like organic concrete. Over a lifetime, your arteries become clogged with the concrete.

So.

The western diet and lifestyle lacks many important things required for healthy living. One of these is sufficient sun. Although Vitamin D supplementation is absolutely required for many people (most science is indicating that 2000 IU isn't even enough but is a bare minimum), we also have extremely little K2 in our diet compared to our ancestors, since it comes from certain fermented foods, and we largely no longer eat the correct fermented in sufficient amounts foods, even though it has been a staple of our diet at least 20 or 30 thousand years; long enough that it has changed our gut bacteria to basically necessitate it for many reasons.

K2 is required for signaling of arterial plaque removal, among other things. That organic concrete? It's not meant to be permanent, its meant to merely to stop you from potentially hemorrhaging.

Also, fun fact, anticoagulants that act as K2 antagonists (Warfarin, etc) lead to vastly increased arterial calcification (since, as an antagonist, it blocks K2 signaling). Those anticoagulants also can lead to brittle bones, because K2 is also used for signaling in a few biological processes that want to deposit the calcium in the right place.

So, I could just say "eat healthily", but nobody knows what the fuck that means. Beef liver and hard cheeses are good sources of K2, so is Sauerkraut and Kimchi. Supplement companies also sell good Vitamin K-focused multivitamins, many of which are a oil-filled gelcap with K1, K2 MK4, K2 MK7, and a meaningful D dosage (so its a drop in replacement for your daily D gelcap) (ex: Jarrow K-Right, but all the major good ones have a product like that).

I have seen him speak about his theory on a few well known medical/science podcasts, so I am a little familiar with his work so far. I find it interesting that he isn't a career biologist in any way, but a software engineer. So, I imagine he'd fit in with the HN crowd quite well.

The major part of his theory I think that is interesting is people who have weird insulin responses (ie, have been or are insulin resistant; so, have, had, or will have Diabetes) have largely shaped what we consider normal cholesterol numbers. Also, people who are lean and eat low carb may just naturally have different ratios of cholesterol numbers; iirc part of his argument involves the LDL-P(articles) to LDL-C(holesterol in the particles) ratio or LDL-C to TG ratios, and how it may be that they have "bad" ratios that most doctors would try to treat with statins, but there is actually nothing wrong with them, as other biomarkers and CAC scans indicate there is no increase in arterial damage even though they have "bad" ratios.

So yeah, I'd consider it worth watching, but don't take it as gospel. If it shows up on a streaming service I have, I'll consider giving it a watch.

There are many different schools of thought regarding diet and nutrition. No topic is more controversial since everyone with a stomach has an opinion.

There is science but that has to be believed in. Depending on your favourite foods and your values, you have to dismiss one half of the science as paid for by big beef or the other half as vegan propaganda.

A change in my environment led me to re-evaluate my food choices and I was open minded to completely changing everything. However, I did not go down the butter and bacon route. I became strictly whole food, plant based. This means always cooking from scratch with no processed foods or animal products. It is just an ongoing experiment with a study size of just one.

I did my research and upped my kitchen game. I was surprised at how much I used to enjoy no longer interests me and how easy it has been to stick to a diet rich in vegetables, beans, pulses and much else that I previously never cared for.

So, why am I telling you this?

Well, some believe that a whole food, plant based diet is best for your arteries. Having given it a spin to have a body that I am happy with, I am hoping they are right.

Do your own research with scepticism. Remember that nutrition is highly controversial and, just out of intellectual curiosity, see how it goes on a whole food, plant based diet. Originally I was only going to try and go without processed food for a month, but, with that target met, I kept going and learned more about nutrition just in case there was anything I was missing out on. The only thing turned out to be vitamin B12, which I supplement, with that being the only supplement.

A CT angiogram distinguishes soft vs. hard plaques (and shows narrowing), so that’s the ultimate way to clarify the situation. (Bearing in mind radiation exposure risk and cost, of course.)

Basically the calcium stabilizes the plaque. Unstabilized plaque is what can rupture, squirting out from the artery wall into the blood and forming a clot. High cholesterol can cause deposits in the artery wall simply due to chemical diffusion. Inflammation, often caused by metabolic syndrome/diabetes expands the plaques. Idk, I probably got that wrong, but anyway calcium scores aren't well correlated with risk.

My experience is, your total cholesterol is over 200 (with some more specifics about LDL I can't recall, like 130 or something), all doctors everywhere will then hound you incessantly to get on Crestor, immediately. Diet and exercise don't matter (they cite research showing it doesn't make a difference). Whether you have plaque or not isn't considered, you need to be on Crestor right now to prevent it from starting anyway.

My cholesterol started really going up in my late 40s and I can concur an aggressive change to my diet where I significantly reduced my saturated fat intake and I lost about 20 pounds made absolutely no difference, and my total cholesterol started hitting 300, so I'm on the Crestor. My initial dose did cause me to have elevated liver enzymes and my total cholesterol went to about 170 in about a month, so I'm on an extremely low dose on alternating days.

It's amazing how fast you get into the ER when you come in like that. I got an angiogram within 45 minutes and also had 2 stents in the LAD with 90-95% blockage.

What about troponin? I was told by a Dr that it's more accurate than an EKG.

Edit: I had the word tryptophan before.

RE: EKGs. There are clear signs in the more detailed 12 lead EKG that can show irregularities in the electrical patterns and specifically help pinpoint the location of the active problem.

A real heart attack (MI) -- the kind that can kill you quickly -- is usually not exercise related and the pain continues for many tens of minutes without going away.

PSA: If you experience either type of symptom above, call 911. Don't wait around and don't drive yourself to the hospital. Take an aspirin if you have one handy and you're not allergic to it. Real aspirin, not ibuprofen or tylenol.

[1]: https://www.fda.gov/drugs/safe-use-aspirin/aspirin-questions...

Happy you got stents at the right time.

Are there any labeled datasets "

-Some Software dude, every month since 1971

Then maybe learn a bit more about the domain before posting silly things.

Attach an EKG, have the patient ride a bike with significant exertion.

If there is a lack of blood flow, it will show up in the EKG as alteration of the electrical signals through the heart.

There are still regulatory/deployment/reimbursement barriers to cross, but this is happening.

I had an EKG last week, the analysis comes back "borderline". Running down every abnormality listed (I know my cardiologist has seen it, didn't consider it notable) has a range of possible causes, including the changes that come with good endurance.

Chest pain during excretion is a symptom in my book.

>Recommend everyone to get it

A calcium scan is a ECG gated CT scan(a heart CT). It takes time from the CT machine schedule and it requires radiologists to describe it, meaning it's not infinitely accessible.

Heh, I think you mean exertion

A cardiologist told me (after a calcium test showed 95th percentile for calcium) that what I was looking for was a rapid drop in ability. Not over a decade, but over a couple weeks or a month. Well, I play ultimate, and one day I realized "I didn't get this winded a month ago". So I got a stress test, and it showed "abnormal motion of the heart wall under stress" (that is, not enough oxygen getting to all the heart muscles). They did a catheterization, and I wound up with two stents.

I mean, look, if you get the chest pains, don't ignore that. But it doesn't have to be that way. If you lose athletic ability, or wind, or endurance, in a short amount of time, get a stress test.

Could it be that it takes that long to determine whether those advances are actually worthwhile? I can’t count the number of HN posts I’ve seen touting breakthroughs in medical research that ultimately didn’t pan out.

Look at the adoption of CAR-T therapies. It took 3-4 years before they were regularly used in the US.

You are right about one point: You should absolutely not trust a random medium article, anyone can write medium article. Instead you should follow the links, then decide whether the experts quoted in the NYT and Bloomberg articles have a point.

There's a pretty direct analogy to type 2 diabetes and metabolic disease generally. The human body naturally produces blood glucose and we would quite quickly die if our blood glucose levels went to zero. That doesn't mean that hyperglycemia is healthy and in fact, we know it directly causes all kinds of bad health outcomes. We absolutely need some LDL cholesterol, and in our evolutionary history when we faced famine there was probably some selection for people whose livers didn't aggressively metabolize LDL particles from the blood (an energetically costly process), but that doesn't mean that high LDL cholesterol today is safe if you're hoping to live a long life.

And yet lowering cholesterol using statins has proved beneficial for people who have already suffered heart attacks. How do you explain this? One explanation is that statins work for these people not because they lower cholesterol but because they reduce inflammation and stabilize plaque.

The science behind this is not fully understood. Big Pharma has no incentive to research this because they are raking in money, and any further research could only slow down the gravy train at best.

[1] https://www.nejm.org/doi/full/10.1056/NEJMoa0800742

- Is it not true that the existence of a link between high cholesterol and heart disease is only a hypotheses that originated in the 1950s, not a scientifically proven fact?

- Is it not true that the FDA generally has not required drug companies to prove that cholesterol medicines (such as statins) actually reduce heart attacks before approval?

- Is it not true that lowering cholesterol by different means (i.e., other than statins) is not beneficial, and does that not mean cholesterol is not the villain it is made out to be?

- Is it not true that the only large clinical trial funded by the government (rather than drug companies) found no statistically significant benefit at all?

What exactly are you saying is wrong?

However, there is zero financial incentive for a physician to prescribe a statin. They are all generic medications. A month prescription is approximately $10.

We do not yet have final word on this topic, we will have a better understanding as time progresses, but until then I continue to recommend statins to my patients with appropriate risk factors, for the same reasons I find climate change credible. The data showing benefit is not just limited to the United States, it is international, and to essentially falsify something involving millions of individuals and thousands of researchers around the world just isn't feasible.

Well, doctors make money when they prescribe drugs: Patients will make more doctor visits when they are on prescription medications than if they are not.

> The data showing benefit...

The reason for the benefit is not fully understood. The argument is that the benefit comes not from lowering cholesterol but from reducing inflammation and stabilizing plaque. The medical community has no incentive to research this because they are raking in money, and any further research could only slow down the gravy train at best.

They are both ECG gated scans of the heart otherwise so they're pretty much the same scan area and same scan duration, if you're hooked for a Coronary CT angiography you can easily get the CAC at the same time by doing a scan sweep before contrast administration (at the cost of 2 minutes of time and an extra dose of radiation)

Though the logistics surrounding contrast administration makes it a bit more fiddly with a slightly higher risk profile.

https://english.elpais.com/health/2025-07-17/revolution-in-m...

Apparently eating too much cheese is a large risk factor.

”we evaluated the full spectrum of nutrient intake and identified a significant positive correlation between ImP [imidazole propionate] and saturated fat intake (driven by high cheese intake)”

Perhaps this depends on the type of cheese consumed.

Of course, it’s a correlation; ImP could be modulating eating habits and making people prefer eating cheese.

There is an enormous scandal to come behind the vilification of cholesterol and the simplification of its level's interpretation to come, which led to the current epidemic of obesity and metabolic/inflammatory/autoimmune diseases. Cholesterol levels vary hugely based on the genetics, epigenetics and lifestyle of an individual, and there is a very large amount of individuals that are within normal range with much higher ldl levels. For example, the cholesterol levels of centennials are usually extremely high.

Things to look out for: - high very small LDL(you need a proper analysis of your LDL levels with a histogram of the size distribution, which is very rarely done and more expensive) - high Triglyceride/HDL ratio(in US units, anything above 2 is not a very good sign) - high hbA1C (metabolic issues) - high lp(a) and/or lp(b) - high hs-CRP (general inflammation, but can be caused by infection if you are sick)

Usually those are all related and high when affecting a normally healthy individual).

Yes and no: the study linked to in the El Pais article suggests that certain bacteria are converting histidine to imidazole proprionate.

More histidine -> more food for those bacteria -> bacterial overgrowth, dysbiosis and increased ImP levels -> eventually atherosclerosis.

There are probably some microbe(s) capable of outcompeting the ImP-producing ones even in the presence of increased histidine, which would serve as a mitigating factor.

One close friend died of a heart attack at 42 and another found a 95% blockage after his CAC scan came back north of 900 at age 40. I'd get it if it's available, the ability to catch certain catastrophic conditions is invaluable.

This really says something to me about American medicine. Something is going to get you at some point. Is something that has a 80% risk of not happening really justify medication which comes with it own cost and risk?

Another article on this topic was posted a few weeks ago and prompted the same reaction in me.

In India this is common. They probably use the same expensive machines for x rays and MRIs but anyone can walk in, and pay for a diagnostic test and get numbers (well, not everyone can afford it, but generally middle class folks can). I’m not saying the healthcare system in India is great, but this distinction intrigues me. Maybe the volumes are much higher in India so the diagnostic center can recoup costs? Are there laws preventing this business model in the US?

It is no issue at all to ask for and receive an echocardiogram referral since it has no risk, just ask for a referral.

The unwillingness to do anything involving radiation unless warranted seems reasonable. Just do the echocardiogram and go from there.

I got a CT angiogram from a cardiologist here who started her own business specifically to do them. (It’s just her, a nurse, and a CT machine, in a trailer in a parking lot!) Insurance doesn’t pay for imaging like this until things have already gone very wrong, and she feels it should be used much earlier for people who have risk factors.

[0] https://prenuvo.com/

For example: https://radiologyassist.com/MRI.html

Any decent doctor should agree to this. Once you have a reference you'll be put through a battery of tests. Blood tests, ECG, ultrasound, etc. A lot of it was covered by insurance anyway but it was out of network for me. That didn't matter to getting the reference though. The tests they do are all non-invasive and not risky in the first phase so definitely worth doing.

https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate...

Cholesterol is a substance the body naturally produces and requires for many functions. In the brain, cholesterol is essential for building and maintaining neuronal membranes, supporting synapse formation, and enabling myelin production. Statins interfere with cholesterol synthesis in the brain and have been associated in some cases with brain fog or short-term memory issues.

Cholesterol itself is not inherently harmful. It is oxidized cholesterol that causes atherosclerosis.

Antioxidants such as those found in green tea help prevent LDL oxidation.