Most people are told their cholesterol is normal and take that as an all clear. Dr Thomas Dayspring and Dr Daniel Soffer would like a word. Both are Masters of the National Lipid Association, both have spent their careers inside the science of lipids and atherosclerosis, and both joined me to talk about the part of cardiology that gets the least attention: what to do before anything has gone wrong.
Atherosclerosis is close to universal. Almost all of us are building plaque, and yet most of us will be told we are fine because our numbers sit inside a population reference range. That is the tension running through this conversation. Dan and Tom disagree, politely and pointedly, about whether ApoB should be called the cause of atherosclerosis or merely its necessary substrate, and about how hard to push in someone with no symptoms and no visible plaque. What they agree on is that “primary prevention” has become a category so broad it is almost useless, lumping the twenty-five-year-old marathon runner in with the sixty-five-year-old diabetic whose calcium score is three thousand.
What We Cover:
- Why the worst single gene variant for atherosclerosis carries less risk than smoking, high blood pressure, or diabetes
- The one real disagreement of the episode: is ApoB the cause of atherosclerosis, or the necessary substrate?
- What a weekend on call looked like for Tom in 1975, and the 80% fall in age-adjusted cardiovascular mortality since
- Why “normal” cholesterol is a population average rather than a physiological target
- The LDL-C years calculation you can run on yourself in about five seconds
- Tom’s answer to the charge that he is too aggressive, which is more moderate than his reputation suggests
- What the 2026 guideline changed, including why your postcode now feeds into the risk calculator
- The muscle ache protocol: how to work out whether it really is the statin
Prevention is rarely urgent, which is exactly why it gets deferred. If you take one thing from this conversation, make it Dan’s line: assess the risk, personalise it, reevaluate.
To connect with Dr Thomas Dayspring, find him on X, where he posts as @Drlipid. To connect with Dr Daniel Soffer, visit his Penn Medicine profile.
- How Atherosclerosis Actually Begins (00:00)
- Do Your Genes Determine Heart Disease (06:14)
- Primary vs Secondary Prevention Explained (13:55)
- The 8 Habits That Prevent Heart Disease (19:10)
- Why Heart Disease Is Still So Common (22:44)
- Is ApoB The Real Cause Of Heart Disease (33:06)
- The ApoB Number Where Plaque Stops (41:12)
- The New PREVENT Risk Calculator Explained (49:39)
- Risk Enhancers Your Doctor May Miss (53:26)
- Should You Treat Low Risk Patients (56:35)
- Which Heart Imaging Test Is Best (01:00:21)
- How Guideline Recommendations Actually Work (01:05:15)
- What ApoB Target Should You Hit (01:08:37)
- Which Cholesterol Drug Is Best Tolerated (01:16:43)
- The New Oral PCSK9 Inhibitor (01:23:55)
- Cholesterol Drugs During Pregnancy Considerations (01:26:55)
- High Lp(a) And PCSK9 Inhibitors (01:29:31)
- Practical Steps For Primary Prevention (01:31:54)
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More about Dr Thomas Dayspring
Thomas Dayspring, MD, 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, he moved to Virginia in 2012, where he served as an educational director for a nonprofit cardiovascular foundation and later as Chief Academic Advisor for two major CV laboratories until mid-2019. He’s currently a virtual cardiovascular educational research assistant and clinical lipidologist at a prestigious national practice.
Career-wise, he has given over 4,000 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 appeared on several podcasts. Until 2019, he was an Associate Editor of the Journal of Clinical Lipidology. He was the recipient of the National Lipid Association’s President’s Award for services to clinical lipidology in 2011.
He has over 25K followers on his educational Twitter feed (@Drlipid) and is a Social Media Ambassador for the European Atherosclerosis Society.
More about Dr Daniel Soffer
Dr Daniel Soffer is a full-time clinician and educator at the University of Pennsylvania. He is an Associate Professor of Medicine at the Perelman School of Medicine and a clinical lipid specialist whose focus is preventive cardiovascular medicine. He is the Director of Education for Preventive Cardiology and Clinical Lipidology at the University of Pennsylvania, co-Director of the Preventive Cardiology Fellowship Program at Pennsylvania Hospital, and co-Director of the Perelman School of Medicine’s Foundations of Culinary Medicine course.
He is a Diplomate of the American Board of Internal Medicine and the American Board of Clinical Lipidology, and a Fellow and Master of the National Lipid Association (NLA), a Fellow of the American Heart Association (AHA) and the American College of Physicians (ACP), and a Member of the Academy of Master Clinicians at Penn Medicine.
Dr Soffer’s educational focus is on the impact of atherosclerosis on individuals, the community, and society, and the role of lipids and lipoproteins in this process, with a special interest in inherited disorders of lipids and lipoproteins. His approach to education is to translate complex science into clear language and images that don’t require advanced training to understand. He is involved in multiple education activities at the University of Pennsylvania, the National Lipid Association (NLA), the Philadelphia Lipid and Atherosclerosis Club (PLAC)/Philadelphia Cardiovascular Institute, and various continuing medical education ventures.
He is involved with multiple NLA activities, including leadership, administration, education, meeting planning, and editing. He was President of the National Lipid Association (2023-2024) and President of the Northeast Chapter of the NLA (NELA) (2018-2019). He was co-editor of the NLA journal LipidSpin (2015-2020) and is an Associate Editor of the Journal of Clinical Lipidology, as well as co-Director and lecturer for the NLA’s Foundations of Lipidology course and recipient of the NLA’s Clinician-Educator Award (2025). He is also co-Director of the Philadelphia Lipid and Atherosclerosis Club (PLAC).
In addition to clinical medicine, teaching, writing, and editing, he participates as an investigator in ongoing clinical research on lipid-modifying pharmacotherapies and population health initiatives.
He earned his BA and MD from the University of Pennsylvania and completed his Internal Medicine residency at the Hospital of the University of Pennsylvania, and has practiced his entire career, since 1997, at Penn. Dan has been married to Gwen since 1990, and they have three grown children together, Maddie, Ben, and Joe, and two poodle mixes named Petunia and Buttercup.
