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Peter Attia MD#129 - Tom Dayspring, M.D.: The latest insights into cardiovascular disease and lipidology
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At a glance
WHAT IT’S REALLY ABOUT
Dayspring and Attia on ApoB, HDL, Lp(a), and New Therapies
- Dayspring says guidelines have converged on atherogenic ApoB-containing lipoproteins as the driver of atherosclerosis, and both he and Attia now prefer ApoB over LDL-P because it is consistent across labs, cheap, and tracks risk better than cholesterol metrics.
- HDL cholesterol is described as a poor metric: trials raising it have been neutral or harmful, and HDL function is too complex and costly to measure, so the speakers advise against spending money on advanced HDL panels.
- Lp(a) is presented as a largely genetic, underrecognized risk factor that should be tested once; antisense drugs to lower it are in early trials, while PCSK9 inhibitors lower it variably.
- On therapy, Dayspring favors starting statins at lower doses and adding ezetimibe or the liver-selective bempedoic acid, and he discusses high-dose EPA (REDUCE-IT) versus a stopped EPA/DHA trial, along with underused fibrates.
IDEAS WORTH REMEMBERING
5 ideasPick ApoB and stick with it
Dayspring and Attia say ApoB immunoassays are standardized, cost only a few dollars, are named in guidelines, and avoid the discordance and shifting reference ranges of NMR or ion mobility LDL-P.
ApoB tracks risk better than non-HDL cholesterol
Dayspring cites Sniderman's work showing 20-30% of people are discordant between non-HDL cholesterol and ApoB, and risk follows ApoB when they differ.
Lowering plasma cholesterol does not starve cells
Attia and Dayspring argue that most body cholesterol sits in cells and that cells can synthesize it, so very low ApoB or LDL cholesterol does not deprive tissues; Dayspring says there is no signal of harm with current approved drugs.
HDL cholesterol is not a useful target
Observational associations were unadjusted, and trials and Mendelian randomization studies of raising HDL cholesterol have been neutral, while HDL function remains impractical to measure.
Lp(a) should be tested once and is not a treatment target yet
Dayspring notes it is genetically determined, recommended once by European guidelines, and not an accepted goal of therapy, with current strategy centered on aggressively lowering ApoB and other risks.
WORDS WORTH SAVING
5 quotesFolks, there's one cholesterol molecule. I don't care whether it's in your cell, whether it's in any lipoprotein in your brain. If I drew you the structure of cholesterol, it's identical. So how dare we a- put an adjective on it like that's good and that's bad.
— Dr. Tom Dayspring
So don't have a panic attack if you're making LDL cholesterol 30, because I can assure you virtually every cell in your body, even if that's your plasma LDL cholesterol, has more than enough cholesterol because it can de novo synthesize it.
— Dr. Tom Dayspring
But right now, don't waste your money. You're going to get an HDL cholesterol. Everybody's going to be doing a lipid panel. Do not waste your money, time, or your brain energy on trying to figure out these HDL metrics.
— Dr. Tom Dayspring
I'd be a fool if I told you I normalized your non-HDL cholesterol and I've eliminated your lipoprotein-mediated risk.
— Dr. Tom Dayspring
I love the, uh, best advice is choose healthier parents.
— Peter Attia
High quality AI-generated summary created from speaker-labeled transcript.
