More on that HDL-C

Because…you never know.

Peter Attia put up a new podcast this week on this very topic. I’m not even halfway through it…not because I’m skiving off my treadmill training/Z2/MAF/ASCVD mitigation stuff but it’s a topic so complex that I’m having to listen over again to the first 50 odd minutes just to get the gist, let alone understand the nuances. Talk about “…the more you know that just ain’t so

Was sidetracked into reading this article (part of the reading list mentioned on the podcast) which is also above my pay grade…

It’s easy to see why ASCVD risk management at primary care level is so, well…lacking


And by incredible coincidence, my FB memories had a photo of my teaching kit from 8 years ago (probably a Friday or close to)…regular bike shorts, red jersey, red earrings, red sweat towel (with hearts…probably a Valentine’s towel from Marshall’s) and HR monitor prominently displayed.

Then I get home from dropping Bebe off at school to this radio programme on the fridge.

…specifically about misunderstood, mismanaged and misdiagnosed cardiovascular disease in women. Per the BEEB it was a repeat of yesterday afternoon’s programme so definitely a coincidence

Two take homes from things I’ve recently read.

1 - women don’t present with the classic textbook chest pains that men do. The first acute MI I diagnosed as a resident was in a woman that came to the ER just feeling tired and nauseated. Since she was a diabetic and EKGs are cheap and easy, ordered one. Had the classic “tombstone” pattern and we were pushing streptokinase within minutes. Another woman I started a cardiac workup on was a patient presenting for outpatient surgery. When asked about her exercise routine, she said she got really tired when walking a couple weeks ago. Had to stop and sit. Did it ever happen again? No, but haven’t been walking again either. Got into a long argument with the surgeon about rescheduling the surgery but was ultimately proven right when she got 2 stents placed.

2 - HDL has a “U” shaped risk profile. Too low and too high has increased risks for vascular disease. You want to be between 40-80.


Yep. This programme on the fridge has examples of women presenting atypically …and with conditions rarely seen in men . Spontaneous dissection of the coronary arteries and Takotsubo cardiomyopathy to name but two.

Peter Attia had this guest on his podcast a while back. You can bet I listened the heck out of this one (and read the heck out of the “show notes”)

Among some of the reasons she gave for the suboptimal care (including preventive) that women get were the Usual Suspects…underrepresentation in studies, tendency to soldier on and power through symptoms, less likely to be offered statins (the man’s disease perception) and, if offered statins are less likely to follow advice. Not that much of a surprise to me, but this cardiologist has observed that women are generally more likely to take to the internet on such topics to “do their own research”…and get seduced by those resources that tend to push the cholesterol denialism/anti statin agenda.


So it looks like this may possibly, perhaps, peut etre be an idea whose time has come. The daughter had a follow up visit with her PCP yesterday to review blood work etc and she texted me to say that she (her PCP) had noted a steady rise in her HDL-C and, although her non HDL-C was in the "normal " range, a CAC scan might be a prudent idea.

Not sure if she’d actually mentioned my issues and belated realisation of a strong family history but regardless her physician did say that in someone like my daughter…an excellent custodian of her body like her mama…genetics plays a bigger role in the development of ASCVD than random numbers on a lipid panel. Just treating the “random number” as a possible red flag at the moment pending the results of the CAC scan…but that was me a few months back.

How unlucky is that in Life’s game of cards…the kid’s been dealt a double whammy. Dh’s aortopathy (the one she diagnosed literally as his previously undetected aortic aneurysm was on the verge of dissecting) AND my ASCVD.

I shall be checking her feet for early signs of bunions moving forward!