In Episode #253, Dr Thomas Dayspring joins me to round out our three-part masterclass on blood lipids and atherosclerotic heart disease. In Episode #251, we covered what blood lipids are and what happens when things go wrong within the lipid transportation system, and in Episode #252 we looked towards how to test and understand your blood lipids as an individual. Make sure to listen to those episodes first.
“If there was widespread improvement in nutrition and lifestyle there would certainly be a lot less [of] many chronic diseases, including atherosclerotic heart disease. But by no means can you eliminate this with lifestyle alone.”
In this episode, Part Three of the lipid series, we discuss interventions to lower risk of atherosclerotic cardiovascular disease (ASCVD). Both Dr Dayspring and I believe in a lifestyle-first approach to lipid optimisation. As discussed in previous episodes with the likes of Dr Gil Carvalho and Dr David Jenkins, there is no doubt that nutrition is the most powerful lifestyle tool we have to dramatically lower ApoB. In some cases, certain people will be able to lower their ApoB by around 30% through diet alone.
In other cases, where people have a genetic predisposition to higher ApoB, or cannot sustain dietary changes, pharmacotherapy is required to optimise lipid levels and achieve low risk of ASCVD. This conversation is designed to help you better understand the treatment options available if you do require a pharmaceutical approach. As Dr Dayspring says: you need to be your own advocate, which means developing some level of understanding to gain more autonomy over your health.
At this point in the lipid series, Dr Thomas Dayspring needs no introduction. He is a Fellow of the American College of Physicians and the National Lipid Association. He is certified in internal medicine and clinical lipidology and has brought an invaluable wealth of knowledge to this series. As you’ve seen in Part One and Part Two of this series, he is also incredible at communicating complex information in an accessible way, supported by the illustrations you’ll see in the YouTube versions of the podcast.
Given Dr Dayspring’s expertise in both research and practice, this episode focuses almost exclusively on the available pharmaceutical drugs to lower ApoB, an elevation of which is essential for developing atherosclerosis. We walk through four main drug classes – ezetimibe, statins, bempedoic acid, and PCSK9 inhibitors – discussing their mechanism of action, effectiveness, and safety profile.
We cover the history of treatment options for ASCVD, tracking the drugs that have been available over time and the main treatment options available now. We also discuss current trials that are running, potential interventions in the future, and much more.
Specifically, we discuss:
- Evolution of cardiovascular disease treatments (03:42)
- Are we becoming a drug-dependent society? (07:30)
- Bile acid sequestrants, statins, and more (13:54)
- Cholesterol-lowering drugs and cognition (35:12)
- Is Bempedoic acid a good statin alternative? (47:39)
- Ezetimibe and nuances you should know (55:46)
- PCSK9 inhibitors (1:03:32)
- Do statins increase the risk of diabetes? (1:14:58)
- Gene therapy targeting PCSK9 (1:19:20)
- Pelacarsen for lowering Lp(a) (1:23:48)
- Can we take drugs that raise HDL to lower cardiovascular disease risk? (1:26:38)
- HDL and atherosclerosis (1:34:59)
- Elevated triglycerides and atherosclerosis (1:46:48)
- Takeaways (2:05:12)
- Outro (2:08:31)
In cases where someone already has existing ASCVD and ApoB target levels are much lower, it is much more likely that pharmacotherapy will be required to restore physiologic levels (the level we are born with) of ApoB. With this in mind, my personal philosophy on lipid optimisation is to not look at this as an either/or scenario. My advice is to make as many sustainable dietary changes as you can – and then, if required, use the least amount of pharmacotherapy to achieve an optimal ApoB (<80mg/dl if low risk, <50 mg/dl if moderate to high risk).
The rationale for this is two-fold. One, the dietary changes required to improve ApoB will also benefit other risk factors for chronic disease. Two, while lipid lowering drugs are incredibly effective at lowering risk of ASCVD, they are not without risk.
If you are currently struggling with ASCVD or are at risk, I hope you found this episode and series empowering. Even if this does not appear to be a concern for you in the foreseeable future, it’s important to be equipped with this knowledge on one of the Western world’s biggest killers. Dr Dayspring offered extremely well-informed insight into this topic over the course of this series, and I am grateful to have had a field leader on the show to embark on this deep dive.
The best place to connect with Dr Thomas Dayspring is on Twitter, @DrLipid. Learn more about Dr Dayspring’s career and current work on LinkedIn.
To assist with the digestibility of this content, Dr Dayspring, my team, and I have included extensive illustrations and graphs to the video format of these episodes. If you are visually inclined, you can watch these episodes on The Proof YouTube channel. Even if you prefer listening through audio the first time, I highly recommend coming back for a second pass with the video versions. These episodes are investments into a healthier future.
We are also currently working on a summary PDF highlighting the key learnings from each part of the series. To receive a copy of this simply submit your email at theproof.com/lipidseries. We are also working on transcripts for these episodes, with the release date to be advised soon.
The best way to support the show is to use the products and services offered by our sponsors. To check them out, and enjoy great savings, visit theproof.com/friends.
More about Dr Thomas Dayspring
Thomas Dayspring, who resides in the Richmond, VA area is a Fellow of both the American College of Physicians and the National Lipid Association and is certified in internal medicine, and clinical lipidology. After practicing in New Jersey for 37 years, in 2012 he moved to Virginia and served as an educational director for a nonprofit cardiovascular foundation and later as a Chief Academic Advisor for two major CV laboratories until mid-2019. Currently, he is a virtual cardiovascular educational research assistant & clinical lipidologist at a prestigious national practice. Career-wise he has given over 4000 domestic (all 50 states) and international lectures, including over 600 CME programs on atherothrombosis, lipids/lipoproteins (and their treatment), vascular biology, biomarker testing, and women’s cardiovascular issues. He has authored several manuscripts and lipid textbook chapters and performed several podcasts. Until 2019 he was an Associate Editor of the Journal of Clinical Lipidology. He was the recipient of the 2011 National Lipid Association’s Presidents Award for services to clinical lipidology. He has over 25K followers on his educational Twitter feed (@Drlipid). He is a Social Media Ambassador for the European Atherosclerosis Society.
- Bempedoic Acid and Cardiovascular Outcomes in Statin-Intolerant Patients • PMID: 36876740
- Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia • PMID: 30415628
- Cholesteryl Ester Transfer Protein Inhibitors and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials PMID: 32172237
- Clofibrate and niacin in coronary heart disease PMID: 1088963
- Effect of High-Dose Omega-3 Fatty Acids vs Corn Oil on Major Adverse Cardiovascular Events in Patients at High Cardiovascular Risk: The STRENGTH Randomized Clinical Trial • PMID: 33190147
- Effects of extended-release niacin with laropiprant in high-risk patients PMID: 25014686
- Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial PMID: 16310551
- Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group • PMID: 10438259
- Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease PMID: 3313041
- High-Intensity Statin Use Among Patients With Atherosclerosis in the U.S • PMID: 35512860
- Identification of a new plasma biomarker of Alzheimer’s disease using metabolomics technology • PMID: 22203775
- Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel • PMID: 28444290
- Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy PMID: 22085343
- Statins and diabetes: What are the connections? • PMID: 36858834