For most of my career as a heart surgeon, the conversation around heart disease risk centered on cholesterol.
What is your LDL? Is it too high? Should you be taking a statin?
Those can be useful questions. But they can also distract us from a much bigger one: Are you metabolically healthy?
I recently joined the Hormones, Metabolism, and You! Podcast to talk about why I believe we need to look beyond a single lab value when assessing cardiovascular risk.
We discussed cholesterol, LDL, statins, coronary artery calcium scores, hormones, inflammation, and insulin resistance. More importantly, we talked about how all of these pieces fit together when you’re trying to understand your actual risk of heart disease.
LDL is one piece of the puzzle
One of the biggest problems with the conventional approach to heart disease is our tendency to reduce risk to a single number.
For decades, LDL cholesterol has occupied much of that attention.
But your cardiovascular health is more complicated than one cholesterol measurement. LDL can provide useful information, but I don’t believe it should be interpreted in isolation.
That’s why I encourage people to look at the broader metabolic picture.
Are you insulin resistant? What does your blood sugar look like? Are there signs of chronic inflammation? What’s your blood pressure? What’s happening with your triglycerides and HDL? Do you already have evidence of plaque in your coronary arteries?
The answers to those questions can provide important context that LDL alone cannot.
Metabolic health belongs at the center of the conversation
One of the biggest shifts in my thinking as a physician was recognizing how important insulin resistance and metabolic dysfunction are to cardiovascular health.
Insulin resistance can develop long before someone is diagnosed with diabetes. And during that time, metabolic dysfunction can contribute to many of the conditions associated with cardiovascular disease.
This is why I don’t want people walking away from an annual physical believing everything is fine simply because their LDL happens to fall within a particular range.
Heart disease prevention should involve understanding the metabolic environment in which heart disease develops.
That means looking at the whole patient rather than treating one isolated number.
Where do statins fit?
We also discuss one of the most common questions I receive: Should I take a statin?
There isn’t a universal answer.
Statins may make sense for certain people depending on their medical history, existing cardiovascular disease, overall risk profile, and other factors. But the decision should come from an informed discussion of risks and benefits rather than an automatic response to an LDL result.
And medication shouldn’t prevent us from asking what else may be contributing to cardiovascular risk.
If someone is insulin resistant, metabolically unhealthy, chronically inflamed, or living with other modifiable risk factors, those issues still deserve attention.
What about hormones and heart health?
Given the focus of the podcast, we also spend time discussing the evolving conversation around bioidentical hormones and cardiovascular health.
Hormones interact with metabolism and many other systems throughout the body, so cardiovascular health shouldn’t be considered in isolation from hormonal health.
At the same time, hormone therapy is highly individualized. Your age, health history, metabolic health, existing cardiovascular disease, and other risk factors all matter.
The important point is context.
Just as I don’t think we should make cardiovascular decisions based on LDL alone, we shouldn’t evaluate hormones without considering the patient’s broader health picture.
A coronary calcium scan can provide another piece of information
We also discuss coronary artery calcium, or CAC, scans.
A CAC scan looks for calcified plaque in the coronary arteries and can help provide additional information about a person’s cardiovascular risk.
This can be particularly useful when someone’s risk isn’t clear from conventional testing alone.
A score of zero and a high calcium score are very different pieces of information, even if two people happen to have similar cholesterol numbers.
Again, the goal isn’t to find one perfect test.
It’s to assemble enough information to understand what’s actually happening inside your body.
What we get into
In this conversation, we cover:
- What LDL cholesterol can and cannot tell you about heart disease risk
- Why insulin resistance and inflammation deserve more attention
- When statins may be appropriate and why the decision should be individualized
- Bioidentical hormones and the conversation around cardiovascular health
- Who may benefit from a coronary artery calcium scan
- What your CAC score can tell you about cardiovascular risk
- Why metabolic health is such an important part of heart disease prevention
- Practical questions you can ask when evaluating your own heart health
If there’s one idea I hope you take away from this conversation, it’s this:
Don’t reduce your heart health to one number.
Heart disease develops within a much larger metabolic picture. The more clearly you understand that picture, the better equipped you are to make informed decisions before you end up on my operating table.