Episode 370: Dr. David Saenger - Cardiovascular Health & Endurance Training

 


Dr. David Saenger is a cardiologist, ultramarathon runner, and someone who practices intermittent fasting and a low carbohydrate approach with his nutrition. He joined the show to discuss cardiovascular health and complications related to endurance training.

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Studies Mentioned:

Clarke, P. M., Walter, S. J., Hayen, A., Mallon, W. J., Heijmans, J., & Studdert, D. M. (2012). “Survival of the fittest: Retrospective cohort study of the longevity of Olympic medallists in the modern era.” BMJ, 345

Antero J., Tanaka H., De Larochelambert Q., et al “Female and male US Olympic athletes live 5 years longer than their general population counterparts: a study of 8124 former US Olympians” British Journal of Sports Medicine 2021;55:206-212

 

Episode Transcript

David, thanks for joining the show. Hi. Thank you. We were just chatting a bit off the air about ultramarathons. And I know from experience that you like your 50 events and and what do you got coming up? 1.1s I got the three sisters skyline in a couple of weeks up and sisters in central Oregon. I live here in Eugene, Oregon, so it's great. A lot of really good trails and a lot of great things around here, so it's great. Yeah, no doubt Eugene is a Mecca of running, so to speak, so. Yeah, that's right. You get it all. Did did you make it to the to the the championships last year when it was in Eugene. 1.5s Uh, no, I didn't. It was true. You mean that like the truck? Yeah. Yes, sir. I should have specified. That's right. No, it was too hard to get tickets. It was so hard on TV. Impossible to your ticket? Yeah, it is one of those things where, like, Nicole and I were talking. Well, maybe we should make a trip up there and see if we can get somebody That sounds like we made a struggle that we decided to do that. Yeah, yeah, yeah. Just crossed my mind after it being championships this year in Budapest. And we were watching that quite a bit and it's like, it's just been so interesting to see the just kind of the growth of running in general, but then also with some of the different events where like specifically like the 1500 meter I thought was just, just just getting insane how fast you have to be in that event to even have a shot at a medal. Where I was looking at some of the data and it was suggesting that because you got to do three rounds of it essentially just to make just to to have a shot at a medal. And then in order to be in that position, you basically have to build a run like. About like a 335, then a 332 And then if you want a shot at a medal, you probably need at least 330 if not dipping under. So it's just like so fast and a different world than what we're doing. An ultramarathon for sure. Yeah, that's. That's right. Yeah. Totally different. Yeah. Well, perhaps the topic today, though, maybe is as equally of a concern for our track and field friends as it is for the ultramarathon folks out there. And think so. Yeah, it would be. Yeah. There's been a, you know, this topic isn't new necessarily. I think it's been something that's been sort of like in the conversation or floating around the world of running for quite some time now after we've had some situations where people have literally had heart attacks on course during marathons and things like that. And 1.1s I mean, there's a lot of speculation early on, I think, as to like what would cause that and this, that and the other thing. But generally speaking, I think as the the conversation kind of goes, it's kind of like is doing endurance sport, at least to the capacity when you get to marathons and perhaps beyond or in a level of training that would maybe be more suggestive to it crossing over from hobby to passion. Maybe he'll say, is it right? Like where is that margin of diminishing returns or is there a margin of diminishing returns when it comes to. Yeah, cardiovascular health and learned important. The green something. Deal with and think about quite a bit. So I'm a I should say I'm a cardiologist. Don't know if it should mention that. Do do a board certified invasive cardiologist and I have special training in cardiac CT so I've done I can read those studies and I practice general cardiology here in Eugene. And I'm very busy. I've been and I've been practicing cardiology for just 20 years now, so or actually 19.5 years. So yes, I'm pretty busy and I've a lot of experience with this issue. Um, so yeah, guess the interesting question is like, first of all, it's important to clarify the difference between cardiac arrest and heart attack, and then that's often used interchangeably and it's different. So if you see somebody collapse on the field with during a race or something and there 1.9s have no circulation, they need to get CPR and so forth, That's a cardiac arrest. Right. And that might or might not be due to a heart attack. And a lot of times when runners or athletes collapse and have cardiac arrest, they have totally normal arteries. It's not due to a artery disease problem. It's just something else. And there are other other things that come into play then aren't even that rare. There's something called hypertrophic cardiomyopathy, which is a genetic disease of the heart muscle. That is a lot of those people are very good athletes, but they can have electrical instability with their heart and they can keel over and die during exercise. It's not that's actually the most common reason why somebody would just drop dead at a track meet or something like that. And that's so that's a whole different feel. But guess what we're talking about is calcium scores and coronary disease, which is a different topic. So should show go ahead and just like explain that. Or do you want to talk about calcium scores? I can I can explain what they are. Yeah. Why don't we do let's just continue on with kind of an overview of the difference because, I mean, you kind of got it started with cardiac arrest and let's get into some of the others so people have a bit of a lay of the land of what it. Sure. Let the heart health overview, I guess. Maybe. Sure. Sure. Yeah. So so guess the for athletes mean you and for endurance athletes in particular you you know there are other rare diseases but the most common disease to worry about if it's not coronary artery disease is 1.4s hypertrophic cardiomyopathy, which is mentioned earlier. And then then if you're thinking about coronary disease, which is probably the next less common reason why an athlete would. Have a heart attack or cardiac arrest or die during exercise would be doing. Due to coronary disease, coronary artery disease is what we refer to plaque buildup or blockages in the coronary arteries. 1.7s These are the arteries that supply blood to the heart muscle. Remember that heart muscle is a muscle like any other muscle. It meets oxygen. And if what supplies oxygen to the heart is these blood vessels called the coronary arteries, and they can get 1.6s plaque build up in the arteries, which is complicated. What causes plaque? It's probably a mixture of there's something with cholesterol, of course, but then it's not just cholesterol. Also blood pressure affects it. And 1.3s and then what happens is you have an injury to the vessel wall and that causes calcium to respond to the injury. Basically, you have the body tries to heal the injury. And when you have that injury or turbulence or disturbance of the inner lining of the blood vessel, which is called the endothelium, when you when you disturb that, you heal it by laying down calcium. And the calcium is kind of the body's way of of healing the wound. So we look for calcium to see if there's been 1.1s blood vessel injury or damage assessed. The best way to say it so and calcium is really easy to see just by convenience. The calcium is dense and it's a lot denser then tissue than the normal 1.8s vascular tissue or muscle tissue, which tends to be more like a very soft and because it's mostly water. So calcium is much harder and picks up on the scan. So that's why we have this thing called a coronary calcium scan. What that is, is basically a fancy X-ray, that it's usually a Cat scan, but it doesn't actually use the full amount of radiation. And we don't need to use a contrast dye injection. It's just uses the scanner to take a kind of a quick view to pick up calcium and you can pick it up anywhere in the body. So obviously bones are going to pick up a ton. But if you see calcium in an artery, that means that probably that's plaque or. Um, injury to the inside of the artery. And you can pick that up anywhere. You can see calcium in the aorta. You can see calcium in the in the arteries going to the brain. You can see it everywhere. And so if you look at the heart, you can get something called a coronary calcium score. That's the tax that we hear talked about a lot these days. So calcium score is a basically the what you do is you just count the pixels. So it's super easy. You're just counting the number of pixels on the on the image that are lighting up bright light because that means they must be calcium. The only thing that lights up bright like that is calcium inside the body. So you, you count the number of pixels, pixels and that gives you a CAC or calcium score. So a normal calcium score would be zero. You shouldn't have any calcium. It's not supposed to be there. So if you get higher and higher levels, that gives more and more concern that there's been vascular injury, that the blood vessel has been damaged and it's healing and that there might be narrowing of the blood vessel. So that would be you know, that's what we call plaque build up in the blood vessel. Does that make sense so far? I'm sorry to go on so long. Yeah, no, this is great. I have a couple of questions, just 1.2s maybe points of clarification, if anything. So I'm not sure when the the way I'm understanding is optimal is no calcium at all. So. Let's say you go and you get a scan and there is calcium there. Is there a different. Is there like a range of problematic within a certain score, meaning like can you have a calcium that is more problematic, like it's looser or more firm or how does that. Right. Yeah. Yeah, that's a great point. So then then once you look at the so there's different kinds of. Okay, so that's the first thing is that yeah, there is a gradation. So you get a score anywhere from zero to you know you can go well over 1000, 2000. So and then you'll get a percentile ranking if you get your calcium. So they'll give you a percentile which is based on the general population with your ethnic group and your age and gender. How how much calcium is this relative to other people? So you'll get a percent if you go and get a calcium score, which, by the way, think, hey, there's no reason everyone should get one. One of the problems is that it's often not covered by insurance because this is considered a screening test. So insurance doesn't like to pay for screening tests because you're not technically ill yet. So they you'll have to pay out of pocket. But it's really inexpensive, like in my community, get a calcium score for about 200 bucks. So it's really not a lot of money to get because it doesn't entail much technology and much radiologists reading time. So yeah, so that's the that's what you get. If you want to go get one, you can it's easy enough to find somebody who will do the calcium score for you and give you a number. So and guess what you're getting at is a higher score is worse, right? So scores of over a thousand are probably really. Significant and indicate a very what we call very heavy burden of plaque. There's maybe even over 500 is a lot and over a thousand. It's a lot. A lot. It does seem to correlate with age. It should be also a need to mention that you definitely will get a higher calcium score as you get older. It's kind of part of the wear and tear of being human, right? Mean as we get older, there's more wear and tear on our blood vessels. The blood vessel linings are exposed to cholesterol, exposed to blood pressure, exposed to stress and shear stress, and particularly with exercise, more stress. So that will cause the calcium score to gradually increase with age. I guess the other thing you're mentioning is the whole concept of different kinds of plaque rates. So I'll go and talk about that. So there's soft plaque and calcified plaque so you can have plaque and to look at that meaning more than a calcium score. So if you want to know, if you have soft plaque, which means so fat means the buildup of cholesterol and calcium on the inside of the arteries. So once once it starts, you get a little bit of calcium. And then if you get progression, you get more calcium. And then if you get 1.1s it's more inflammation involved in the plaque that's building up in the artery, the the plaque can become more complicated. If we say complicated, meaning it's not just calcium, there's also cholesterol, there's also white blood cells, 1.2s inflammation, inflammatory tissue, fibrotic tissue. There's other stuff in there in calcium. And that's what we call a mixed plaque or a complex plaque or and then if it gets less calcium and more. Immune cells and more 1.9s cholesterol. We call that a soft clack. That's the you'll hear that talked about. To diagnose that, you really need more imaging than just a calcium score. Calcium, remember, is just kind of a very simple thing. It's just counting the calcium pixels. So if you want to know more characteristics of the plaque, then you need to get a real what's called a C.T. angiogram. So Instagram is a little bit more uses the same scanner. But what that entails is injecting dye. So you're going to be injecting contrast into the vein, and then you're going to give quite a lot more radiation because you have to get high 1.1s fidelity, really clear pictures of the arteries. So you can actually see down to the very submillimeter scale of the blood vessel inside the blood vessel. And you can look at the plaque and you can tell, is this just purely calcium or is this a mixture of calcium and cholesterol or mixture of calcium, cholesterol and 1.6s inflammatory tissue or what? So that's going you talk about something called a vulnerable plaque. If you're I don't know if you've heard that already, high risk. You also talk about a high risk plaque or a soft plaque that that would be something to be a lot more worried about. Right. So a soft plaque or plaque that is more 2s full of other stuff than just calcium tends to be higher risks tend to be something to be more. Are likely to burst open. So what a heart attack is, they should probably go back and explain what usually what a heart attack really is, is caused by one of these soft plaques, one of these mixed plaques. It's not purely calcium that suddenly bursts open. So what happens is the the plaque, the the lining on the plaque ruptures or opens and forms a blood clot. And then you get a blood clot in the artery and that obstructs blood flow to the in the artery. And that causes that's that's what you really want to avoid. That's what art attack is and that's what kills people. That's what you mean. Usually that's what you're going to die from when doing exercise this rupture of a soft cloud and guess to get back to endurance athletes, this would be something that is less likely if you have a calcified plaque. So calcified plaque is more stable. So that's actually paradoxically, it's kind of a good thing. You want calcified plaque, you want to have plaque. That's if you had to choose between plaque. I mean, you don't want any clock. It's better zero. But if you're going to have plaque, you want calcified plaque, not soft plaque or non calcified plaque or mixed plaque makes plaque is a lot more likely to to kill you or to cause a heart attack or etcetera. The family planning a pretty cool. Yeah yeah no that does I think it's just interesting because I think sometimes you'll hear people talking about how they got a score and it's zero awesome and zero, which is good. Probably you obviously you'd rather have zero than a thousand like you were saying. But if you have a zero but also have a lot of salt, you could bring a worse shape than someone with a score higher. All right. That's that's controversial. That's really important. You touched on an interesting topic there. This is an area of controversy. So the studies seem to show that the likelihood of that is pretty low, that you're not that calcium does. If you have a lot of calcified plaque, you're going to have some non calcified or more high risk plaque and they kind of correlate. It's very unlikely, although it is possible When people talk about this, it is possible that you could have a score of zero and you could have soft plaque and could be at risk because of that. Yes, it is possible. And there are a few cases of that, but it's pretty unusual. It's in the less than 10%, probably less than 5% range. I mean, that would be pretty darn unlikely. You shouldn't get on and you shouldn't you shouldn't worry about it. It's more like, yeah, I mean, that's not a and then people say, well, gee, should everybody just get a full CT angiogram? Don't even do a Cat score, just get a CT angiogram and that'll that'll detect soft plaque. Right? So maybe you should do that for everybody. But the thing is that a Instagram is a lot more expensive. It's more like $1,500 and entails dye injection. Right? So you're injecting somebody with contrast which can hurt. You can have complications of that, all kinds of complications from injecting somebody with contrast. Plus there's quite a bit more radiation, which is all another thing, radiation exposure. So, you know, I don't know. I mean, there are definitely cardiologists out there who say everyone should get a CT angiogram. I think that's a little aggressive. But I mean, that's yeah, that's kind of what you're what you're talking about. I think the interesting thing for for us, for endurance athletes is, you know, do we need to really worry about the elevated scores in endurance athletes think, you know, that's what you and I would be worried about and I can talk about that if you. Or do you have any more questions about the type scores in general or coronary artery calcifications? No. Well, maybe one more, actually. So is there any variance in let's say we both get scores and we both score 100. So we've got some there. Is there any reason to believe that one person's 100 can be more problematic than another person's 100 if the assuming saw is also equal? Or is it just 101 hundred? 1.1s Uh, according to the big studies, it's just the number. So that's basically like the higher the number, the worse, the more likely that you're going to have events in the long term. But it's over the really long term. That's the things these studies show, like it's years and years, it's not months or weeks, and that more, more calcium is worse. But, you know, calcium score 100 is pretty modest, right? I mean, a calcium score of a thousand is a lot more important. They're recommendations that if you have a calcium score of over a thousand, you probably should get a full angiogram or you should get a stress test or something. I mean, there are even some people who say to do an invasive coronary angiogram and somebody has calcium score over. So I wouldn't do that. I don't do anti-gun. Some people like that just don't. I would base it more on symptoms because, I mean, it needs to be said also that all of the studies in cardiology show that just putting a stent in and opening up a blood vessel doesn't necessarily solve the problem if you're not having a heart attack. So, you know, that's really important. Stenting doesn't prevent heart attacks, and I need to get that clarify. You you have a blockage. It's calcified. Okay. You know, you you can deal with that. But putting in a stent doesn't fix the problem. It doesn't prevent a heart attack. It doesn't do anything like that. So, in fact, it might cause more problems. So, yeah, just want to just make sure that's that's clear. More, more calcium. More pork is is not a good thing, but it's something that you want to treat with, uh, with lifestyle, not with going in and doing angiograms and procedures on people just because of the calcium scores. That makes sense. Yeah. 1.2s So I think the the issue that comes up for for us, for ultra runners is, is there a risk of having I mean, he does correlate. Right. So that's the problem is that running in particular puts shear stresses. You know, blood pressure goes up. Right when you're running. I mean, there's you put a blood pressure cuff on somebody on a treadmill. Their blood pressure is high. I mean, there's you know, it's not like they have high blood pressure. It's they get high blood pressure during exercise. You'll see blood pressures that normally go up to 180, 190 when they're on a treadmill. And then you take them off the trail, do this every day and you take them off the treadmill. It goes back down to normal. That's that's that's going to be some strain, some turbulence on the stresses, the inner lining of the arteries. And there's no way around that. That's what's happening. The question is, is that a bad thing? Right. So probably it isn't, although it does correlate with and because there's so many good things that you got from those. Right. There's so much so many we all know about all the tremendous benefits that you get from having a endurance exercise and from that whole 1.1s experience of doing exercise on a regular basis. But then I guess the question is, you know, like what? What's happening to your arteries? And the studies show that over time, people who do vigorous exercise at high volume do get higher calcium scores. It does correlate. Now, it doesn't correlate perfectly. That's the problem. It's not like, you know. 1.4s There's an exact 1 to 1 correlation, but it does tend to roughly correlate and you get a higher calcium score with with high volume, long duration endurance exercise. What the interesting I guess the interesting study that came out recently earlier this year was the March 2nd study in in the Netherlands. Kind of talk about that. Yeah. Or do you have any more questions? Okay. So that was the big study that came out. The people were generated, a lot of press was they took a group of about 300 athletes in middle aged white men needs to be said. These are not women. These are all men and they're all white and they're all in the Netherlands and they're all like starting at age 50 and then age 60, approximately. 1.1s And they followed them to look at their credit scores. So they took half scores and one baseline. And then again in think it was like five years later and saw the progression, which is about right, about five years is where you'd see any difference. And they found that endurance exercise volume did not mean everybody progressed, right? You'd expect that there was definitely a slight increase in calcium score over five years, which is exactly what you'd expect in any study in the general population. But with these athletes who are doing endurance exercise, the total amount of exercise didn't really correlate with progression. But what did correlate was what they call very vigorous exercise. So very vigorous exercise. And they defined that as being just a little bit confusing how they defined that. But basically they defined that as pretty high workload for a significant amount of time. So probably something like and they said greater than nine months. So to put that into. Real like understandable terms. A met is the metabolic equivalent. That's how we measure exercise in the physiology lab. Right? So, you know, with med is more than nine meds counts as very vigorous exercise in their study. So that's running like beyond a an easy pace I guess that'll be running at like you know maybe intensity level of seven out of ten, something like that or six, something like that would be I think would be nine Mets. 1.3s So that's up there. But it's not like super intense. So that did correlate significantly with plaque progression. So if you take that study as something to, you know, take action from, you would say, you know, if you do high what they call very vigorous, whatever very vigorous means, very vigorous exercise at a high volume, then you're going to have plot progression probably. Does that make sense? Yeah. I have one question along those lines in this valiant, unanswerable question, just based on like not being able to tease this out. But I'd be curious with something like that, where is it like a continuous exposure to nine plus? Or would something where so like is there a difference, say, than if I did like, let's say I did like a lactate threshold field test, which is going to be like or not just like a rich 60 minute race that's going to be around that intensity. Is that going to be worse due to the continuation for those 60 minutes versus if I did say six by ten minutes with a small break and gave myself a relief from that intensity, we can't. Yeah. So that's a really that's exactly what I was wondering when I'm reading this. Yeah. So I'm like, I'm doing the exact bitter 50 training plan and it entails quite a bit of, you know, these, these long intervals. Yeah, Yeah. Hey, the long intervals. Exactly. That's exactly what I'm thinking. So I didn't study that kind of thing. They don't mean there's just not enough data. If you want my opinion, I would say that longer, more exposure to to high blood pressures and shear stress is probably worse. 1.4s Probably will, but mean again. Then it comes back to the question of how bad is the calcium score, right? Mean, is it really all that bad or not? I mean, the the thing that needs to be mentioned is that statins increase your calcium score. Right. We all know that that if you put somebody on a statin, the calcium score goes up. And as a cardiologist, we say that's good, that's not bad because what you're doing is you're healing the plaques and the stones are inducing healing. They're inducing 1.1s fibrosis or stabilization. They make plaques more stable. They stabilize plaque. So is stabilizing plaque may be a good thing, right? Mean And then the other question is, who are these people anyway? Right. Are you running because you already have some plaque and you're stabilizing your plaque that you already have? Right. So, I mean, we don't have the counterfactual. We can't take somebody who, you know, and go back and look like, well, what would have happened to your plaque if you hadn't? Yeah, I just don't know. I think there's just not enough data. I would say that in general, my I guess my take home is that, you know, longer duration at high intensity. Is probably putting more stress on your heart. And maybe that's not a great thing over a long period of time. Am I going to change my behavior based on that? I don't know. I mean, I'm still persuaded that exercise is so beneficial for mental health and for metabolic health and for so many other things. Right. So it's really hard to say if if if that ought to change your behavior or not. Think you should be aware of it. Get a calcium score, you know, check your apob level 1.2s or your lipid profile or whatever. Get get in, get some labs, talk to, you know, get get checked. I guess that would be my my rough recommendation. That's kind of what I would do. Does that make sense? Yeah. Yeah. It's interesting because I think, like, I'm just thinking people listening, thinking like, well, maybe I'll do one less, like ten to a half marathon. 1.9s Yes. Yeah. I just don't know. I mean, do feel better that like, long duration exercise is totally not so salient with, you know, if you're doing like whatever zone two or zone three, even zone three is probably fine. So and they said vigorous exercise is not correlated, but it's only very vigorous. So 1.3s and total volume was not correlated. So and this is the only study that we have that was longitudinal, that looked at a group of people at baseline and most are the same people again five years later. So that's a really valuable data we don't have. There's only one study that shows that. So yeah, I mean, I don't know, I would do, you know, more longer duration, more more ultras that at a kind of easy pace and maybe less super intense like ten KS I guess that's kind of my take home, but again, I wouldn't worry that much. Yeah. Overall, the events in these the number of cardiac events in this population was pretty low, right? These people are not dropping dead everybody. We have this emotional response that we we see an athlete die and we get. It's very emotional. It's very scary, and it really 1.5s makes everybody get excited. But the fact is that the reason why we get excited is because it's so unusual. Yeah. I mean, we see somebody who's who's not an athlete 1.4s or especially if they're if they have a lot of risk factors for heart disease and they have already checked, we say, Yeah, well, that's what you expect, right? You know, so nobody blinks an eye. But you see these cases where somebody who's athletic and has a heart attack that really sticks in your mind and it can cause a, I think, perhaps a disproportionate response to 1.3s something like that. Yeah, you know, it always when when this sort of topic comes up, too. I always think about there's a study out the dig up the link and put in the show notes and then share it with you if you haven't seen it where they actually looked at just like basically like. Life progression in a group of Olympic track and field athletes. So we're talking or I should say athletics for European listeners, but. They looked at that. And the cool thing about that study was they looked at a whole the whole the whole athletics competition participants. You know, it was like you had your shot putters, your discus, your javelin, your long jump, high jump, sprinters, middle distance, long. So you got basically what I would consider like super athletes and people that are just like, you know, peak physical specimens that we have to offer. And then across the spectrum of discipline, when you have athletics, because that's what that does, it's basically testing every type of human physical type of, you know, so people who are obviously all these individuals at that level are somewhat genetically selected because you're not going to throw the shop if you're my size, no matter how hard you work at it and you're not going to run the marathon if you're, you know, if you're someone who's six foot six, £300, you're going to fit on the shop. Isn't that great? So but the cool thing about it is they looked at all these people are and likely quite a bit healthier than the average person and looked at just life expectancy different things that like would potentially happen to them along the way before they died. And the longest living ones of that group were the long distance runners. So. I think there might have been have to double up. There might have been another group in there that was equally as highlighted, the athletes or something like that. But, you know, that's kind of just a smorgasbord of everything at that point. So I would imagine you're probably in a pretty good spot. But but it just goes to show you like if you're running for let's say you're doing the 1500 through the 10,000, somewhere in there, you're going to be doing long intervals and you're going to be doing short intervals for quite, quite a amount of that from probably early life to whenever you retire and then maybe to some degree after retire. So we're probably talking about an exposure to a type of intensity that is both very difficult to actually do because as you know, like on my training plans, there's only so much volume I can prescribe of long intervals and then weigh less even yet on short intervals because there's a limiter your body puts on you. For that, you gets to the point where if I kept getting you that workout, eventually you just wouldn't be able to do it and it wouldn't take that long. Right? So. Right. Yeah, yeah, exactly. Exactly. Yeah. So yeah I mean I those another study that similar like they looked at Swedish 1s cross-country skiers who are over 70 and they scanned them there's like 100 of them and they scanned them all and they all had very high calcium scores. They had calcium scores of like over a thousand, a lot of them very high prevalence because they're seven years old. But they were also endurance athletes and they were healthy. Right. And they're living they have very few illnesses, not a whole lot of other medical problems. And sure, maybe it's irrelevant, right? I mean, if you look at people like that that are doing high volume exercise from endurance exercise for long periods of time, maybe it doesn't matter that they have a high calcium score. I'm not sure. I think I would say I would give one more thought is that if you have a high calcium score, mean probably if you're going to do an endurance event, you might take a baby aspirin beforehand. I mean, that does provide some benefit. 1.2s Aspirin is not necessarily for everybody, certainly not if you're low risk because aspirin can cause bleeding and have side effects for some people. So I'm not telling everybody to take aspirin, but I'm saying that I mean, that's what I do. I mean, you know, I if I'm running a 50 or 100 K race, I know that I'm going to be putting whatever calcium I've got under some stress and probably won't. Nothing's gonna happen. But if I rupture one of those cracks, that's what that's what you want to be avoid. Right. And the one thing that does keep a blood vessel open if it ruptures is aspirin. That's one thing that it's relatively benign. So there's definitely a that's just in my idea. There's definitely cardiologists out there and say, well, if you're going to race, if you're going to do something really intense, maybe take a baby aspirin, because that does mitigate. What exactly happens when you take an aspirin that would make that beneficial? So just two things. Number one, if the same time planetary and a lot of these plaques mean it's important to say that coronary artery disease is to a large extent, an inflammatory process. 1.1s It's not just laying down cholesterol and blocking the arteries. There's inflammation involved, which is one of the reasons why exercise is so good. Right, Because exercise is kind of anti-inflammatory over the long term. And that's why something like smoking is so bad, right? Because smoking is super pro-inflammatory. And that's why a lot of other if you kind of look at it through that lens and a lot of coronary disease makes sense, right? Anything that is inflammatory is probably bad for you. So that's why not getting sleep. It's it's bad for you since it's pro-inflammatory. That's why, you know, mental stress is pro-inflammatory. That's why, you know, I can go on and on like people. There's studies that show that like just the you can look at inflammation. That's the whole thing about CRP, right? Remember, there was all those studies that came out like a few years ago showing that might be more interesting than cholesterol and more meaningful than cholesterol in predicting coronary disease. Right. So what's CRP? CRP is a measure of inflammation. That's all it is. So inflammation is maybe that's more important than cholesterol. And a lot of people think that. So aspirin is is a good anti-inflammatory in taking just a baby dose is probably all you need. And then the other thing that aspirin does is it probably definitely inhibits platelets from sticking together, which makes your blood clot a little bit more slowly, which will if you're going to have a heart attack, it's not it's not going to form that clot that obstructs the blood flow in the coronary artery. Does that make sense? Yeah. Yeah. And just for clarification, for like a baby aspirin work that's different than other like, anti-inflammatories, like ibuprofen, right? Yeah, totally different. Yeah. Ibuprofen does not have that benefit. Ibuprofen. They've studied that. It doesn't really prevent coronary disease. It is anti-inflammatory, but it probably has other bad things that counteract that. It can cause blood pressure to go up. It has other effects we don't even understand completely. So not struggles in general. Probably not so great. Um, and a low dose aspirin is probably preventative. But again, just to clarify, it's not for everybody and it does have some risk. Yeah. What are some of the risks that would be that would entail in that obviously it's like anything you're going to be looking at this through a lens of I want to lower my overall risk factor. So obviously when you're making that consideration, someone who decides that they're going to do it or their doctor tells them to do it, it's because the benefits of it or you just described outweigh whatever those side effects would be. So what are some of the side effects, though? 1.2s Of aspirin can cause intestinal bleeding. Irritate your stomach? It can cause 1.6s in general, it makes you more prone to bleeding. It can. There's a small, very small risk of cerebral hemorrhage, which is terrifying, but that's pretty small. But it could happen. Um, yeah, I think those are the main things that you, you know. So I stop aspirin all the time and low risk people here, you know. Young And you don't have any, any plaque in your arteries and you're, you're totally healthy. Then taking the aspirin doesn't make a whole lot of sense. But if you're, if you're older, especially men, I mean, the studies, again, keep showing that women get less benefit from us. From now you can get any benefit from aspirin, which is weird. It's interesting. Maybe has to do with the fact that women have lower risk in general, but not of get more benefit from aspirin and older people get more benefit from aspirin. And if you have plaque in your arteries, you get more benefit from aspirin. So. Guess. Does that sort of answer that? Yeah. No, that's great. Thank you. Um. Okay, cool. I mean, you should. Yeah. Just mentioned. I mean, it's interesting. A lot of the studies. I mean, we should mention that I was talking about men versus when the studies are all mostly in men and mostly in white men. So I just need to mention that again, we really don't know a lot about other about women and benefits and risks and long distance exercise for I mean, we just don't know as much. There's just not as much data. So, I mean, we have a lot of data on European men. So that's it is it's good and bad. It's good that we have the data. I mean, that's where they do the study is. But it's bad that it doesn't. We're still kind of out. You know, we don't know a lot about women athletes. We don't know a lot about other ethnicities. So, I mean, if you're in doubt, then see a cardiologist can get some more testing and try to sort it out. Yeah, I guess at the end of the day, a lot of this is sort of like an overview of what could potentially be problematic. But really any data that would be suggestive of it being unique to European men versus women versus other ethnicities could be cleared out with individuals by looking in and taking a look at where everything at. It probably correlates, but you have to be careful not to generalize. Not to overgeneralize and be too confident based on the information that we have, which isn't that good. Guess that's the bottom line. Mean I take from this again that exercise does more good than harm. But we should recognize that it probably does a little bit of harm. Mean you can't I wouldn't deny that. So am I going to stop running ultras because of this? No, of course not. But it's just good to be aware of it, I guess. 1.6s Yeah. Do you know, is there, like a general timeline? I mean, I'm sure there is. And if you don't have it off the top of your head, that's fine. But I'm just curious. Like, I'm guessing they kind of stratify this by age groups where it's like if you're in your 20s, you should almost certainly have a score zero. So if a 20 year old goes in and has a score zero, it's like, Oh yeah, I'm just doing what you should be doing versus someone who's like, say, 55, 60, they're going to go in is the I'm guessing the expectation. There is probably not a score zero, but that's likely fine because they're not expected to live as long at that from that point on where someone was in their 20s. Right. Right. I mean, I wouldn't use age as a rigid cutoff rate because, see, that's all the time I see 60 year olds who look like they're 40 and see 40 year olds who look like they're 80. So it's 1.3s really two. So I just don't know. I think family history also comes into play a lot if you if you're 20 year old. But your dad had a heart attack at age 30. That's a lot more concerning, you know, so I think family history is important. Think exposure to other risks, right? So I saw the other day, I saw a patient who was 40 but who had smoked throughout his 20s and then quit. So that's that person would be significantly higher risk, even though they. You know what I mean? They're relatively young. So that would be somebody that would want to do a tax or maybe even get a CT angiogram if the scores are on someone like that. Um, so you got to kind of take the nuance of the of the patient and the individual risk factors into play. That's why I think getting more lab testing is good. Getting a there's something called LP little a I know Peter Attia talks about it a lot on his podcast and it's super important. LP Little A is a, uh, genetically determined risk factor. It's a type of it's a, it's a protein that gets attached to LDL cholesterol and markedly increases the risk from it. It makes it a lot worse of a of a bad actor. If you have elevated LP little A and I've been testing it a lot in patients and it's been really, really interesting when you get elevated. A That's super important. I mean, have patients when I see somebody in their 20s who comes in with a heart attack, it's almost always because they have a high LP and I've seen that like a whole bunch of times. And so that's important. Think everybody. The recommendations are that everybody should get their little tested 1.2s just once in their life. We don't yet have a therapy for that, although it's coming maybe in a year or two. But as of now there's no treatment for elevated LP. But to know about it makes a big difference in terms of knowing your risk. I think of it, it's like being it's about as bad as smoking, it's that bad and it's kind of like smoking that you can't quit. Yeah, yeah. So it's if you were a smoker and couldn't quit and had that exposure, I think you ought to know about that. That's something that's worth worth finding out. So I think everybody every everyone should get their little tested. Yeah. And I think just like you mentioned, this is a some this is a situation where these are risk factors. They don't make they're not guarantees. Right? So it's one of those things where you have a high LP LP and then that may just be an indication at this point in time you should probably have all your ducks in a row on the other ways to lower your risk versus someone who's lower. They maybe don't have as much mean. They probably should still be mindful of the other risk factors, but maybe they don't have as much of an incentive. Exactly right. But 1.1s if you're if you have LP little, it is validated. Had this happened? Actually just recently I had a patient who I just did her LP little A and it was like super high and I'm like, you really, really got to quit smoking. Oh, my goodness. Yeah, Yeah. You really don't want to combine, you know, there's a synergy of risk, right? If you combine high blood pressure and smoking and elevated LP little, you're really guaranteed to have a problem. So Absolutely. Yeah. You know, you mentioned Dr. Peter Attia, and one thing that he said that I thought really kind of summed up the cardiovascular risk, 1.3s the factors and how to think about them was he described as everybody is just imagine yourself being a car and this car has a minimum. Like, let's say you're neutral, so you're just coasting. That's the slowest you can possibly go. And the and like all these cars are going to the cliff. The cliff is when you die, obviously. So you can do things along the way that either hits the accelerator or hits the brake on that that progression towards that cliff. So like, let's say if someone has high a little a, they just have a little bit more of a static foot on the gas pedal that they're not going to be able to nibble. So then if they start smoking, pushing that gas bill down further and then eating a diet, that's higher risk and all these other things, and they just push you further and further down and getting closer sooner. And that's the way to make me think about it, whether you're dealt a poor hand or not. 1s Exactly. Yeah. Think so? Yeah. And then there are tools that we have to. To mitigate risk. Right? And, um, you know, statins, a lot of people, they do great with them. Not everyone. Of course, there are people that are stand intolerant. But if you can tolerate statins and they they're they're great. There are other options. Now, there are a whole bunch of other drugs that have come out in the last ten years that are really effective in lowering the apob, which is the best way of looking at cholesterol. It's just it will be levels. So there's that. There's and then we're talking about if we're talking about higher risk, usually athletes don't have high blood pressure. But if you're having I mean, there were some in that study, by the way, the the the study out of the Netherlands had like I think 20% of them had or 15% had high blood pressure. So there are athletes with high blood pressure out there. So if you've got that, then treat that should be treated that will lower your risk. Right. There's a lot of things you can do to reduce your you get better sleep mean it's super sleep. I keep thinking about how sleep is super important. So there's a lot of things that we can do to to take our foot off, I guess. But for the 1.2s food. I have a couple questions for you. Sure. Just to kind of get a like I find like a lot of these topics are really interesting because it's one of those things where if you go a layer deep in a certain community, you find things to be very problematic or be like like the the savior of us all sort of thrive mentality. And then when you go a few layers deep, you kind of find the nuance within it and where the middle ground guess is where it usually ends up falling. So if we look at statins in general, I mean, I've seen everything from like if your doctor recommends a statin, you go find a different doctor, like full stop, like no longer duration to, to like we should put statins in the drinking water. Like, well what's the deal with statins in general? Like, I assume it's like anything and there's a risk factor there for certain populations. Maybe, or things that are going to maybe be suboptimal with them. But if it's something that's going to prevent you from dying earlier, you might want to take that. Is there can you just give us an overview of that? Yes. You happy to? Yeah. So Stan will lower your April level. And if it was very low, it's very clear that April is anthropogenic, so it caught meaning causes plaque to build up. So Stans will lower that. And they also there's studies, numerous studies that show that they induce plaque regression or stabilization so that it takes that that high risk plaque that we talked about and it converts it into a calcified plaque that's more stable, less likely to cause a heart attack. And then there's epidemiologic studies like maybe work looking at large groups of people over time that show that the ones on the statins had a significantly lower risk of death. Heart attack, stroke. ET cetera. So there's the data showing benefits of stuns is is just overwhelming. That being said, you know, our other I mean, not everybody can tolerate statins. I'm one I can't so far I mean I tried and I, I had I had full randomized analysis on a run from. Oh really. So yeah. Yes. Doing one of your one of your health and well my thought was it. Yeah. Well you know the stands fall well. 1.6s Right. So, yeah, I've been taking this time for a couple of months and no problem. And then I did like a 1.1s low medium intensity 90 minute run and was going downhill at a brisk pace and all of a sudden had stop and I was like, Oh, my, this is unbelievable. And I went in and got my blood levels checked and my level was like several thousand. I can't remember. It was really high. And so, yeah, okay, I stopped the study and waited like a few days and I was fine. I went back to running. No big deal. I mean, it's not like any major damage was caused. So I think people get a little too emotional. 1.5s I mean, people yes, there's about recognized incidence. About 5% of patients, maybe 10%, cannot tolerate sentence because of the muscle pain to sadness cause dementia. No, that's not true. That's just because other. No, in fact, they probably do good. They do raise blood glucose a tiny bit. So there's that whole thing. But it's enough to cause diabetes? Probably not. It raises your blood glucose by about 1% or something like that. According to most studies. It's really probably not significant. So, you know, it's a tool. I was thinking statins are a tool to use to reduce your risk, but it's not the only tool. There's was a big study that came out recently that showed that backpedic acid, which you might have heard of, it's called Next Little Came Out. That's a drug that came out just about 3 or 4 years ago, and it actually did just as well as statins in terms of reducing outcomes and excellent a different pathway or it's higher up on the cholesterol synthesis pathway in the liver. So it blocks the liver for making cholesterol in a different, totally different way and does not cause any muscle problems at all. So you can take vampiric acid if you don't want to take a statin probably does the same benefit. There's Zetia which works totally and that's cheap. That came out a while ago. It's generic now. That works not as well, but it does. Something does. It's probably beneficial for reducing risk. And then there's other options. There's this drug, the five minute bitters, which are injectable, which is a little bit of a hurdle for some people, but. Once every two weeks, you inject yourself with this drug that it's a long stroke, how it works. But basically it lowers cholesterol more than statins. Very expensive, but it does work and it's got no side effects, pretty much. So there are other options out there. So I always try to work with when I have a patient who says that they don't want to take a stand and they say like, you know, let's talk about different options. So there's different statins, right? I mean, you can do a lot of people do they get away with doing a lower dose of a more milder statin? They're milder ones that are water soluble. That leaves your body quicker. And you can do that. You can do it twice a week or three times a week, have a lot of patients who take statins three times a week and have no problem. So there's a lot of different ways to skin that cat of getting your level as low as possible. It's not like I mean, also use lower doses. I mean, a lot of doctors I see given way too much high doses of stands, which are a lot higher risk of causing side effects. So somebody comes into my office on like 80mg of Lipitor, my TV. So there's no it's not necessary. You can give a low dose and they'll be fine. And the risk is a lot lower. So is there it sounds like this is probably would just be a temporary solution because it sounds like we're we're continually developing this sort of therapy to a point where eventually we'll have something that has all I shouldn't say all, but like it has like so many benefits in the trade offs are so slow. It'd be silly not to do it type of a scenario. But if someone were to say, have a situation like you did where they were having muscle issues with the statin, but it was by and large very proactive for their cardiovascular health, would you be able to do like could you dose it on like an off season where like you take in a break from running or maybe you're reducing filing and then get some benefit and then phase out of it during your peak training when it would maybe be problematic. 1.2s That's a clever idea. I've never thought of that. Sure. I mean, you can try it. I mean, there's no You can definitely do that. You can cycle therapy, or you can switch around. Yeah, you could do that. I don't know. I mean, my experience is that if you're going to have if you have full blown I mean, there's a difference between muscle pain, like just an ache and pain and full blown like lab labs that show muscle injury. Rob Joe 1.1s Yes, it's a little bit more concerning because if you have dog, then you can injure your kidneys and you can have other issues that happen from that. So I don't know if I would screw around with it too much if you had rabideau, but if you just said muscle pain, then that's allowed milder, then sure, you can end there. Ways to mitigate that too. Studies show that if you have muscle pain from stents, check your thyroid because that's associated with a higher risk of problems and check your vitamin D level to a low vitamin D, then that makes it a higher risk. So yeah, I mean, there's definitely ways to kind of negotiate around that. For sure. 1.2s I did want to touch on one other thing you mentioned, and that's Appleby. As that has been something has come up a lot more as sort of maybe a little bit. I've seen a bunch of different things. I've seen like, okay, this is the number you really want to test. It's not on a typical lipid profile, so you sort of have to request it, Right? And I've seen other geologists suggest, yeah, it's a great test to get, but it also correlates so nicely with some of the other stuff that really you can kind of pretty much predict you're able be with some other stuff anyway to just talk about like, well can Yeah, sure. Yeah. So, so Appleby is the that's the academic part of all the AstraZeneca with say it should be careful pathogenic means something that causes plaque to build up so we say the word allergenic so all of the anthropogenic or bad 1.8s lipid particles have attached to them. So HDL is not a genetic there's not a vapor be attached, but vldl 1.2s triglycerides, they all have. It will be. So if you just look at the number, that's a lot simpler and easier than what you're what you're referring to is can you just like just look at the total cholesterol and people do what's called the non HDL cholesterol. So you take the total cholesterol and subtract HDL, and then you're left with all the bad particles. The reason why that's not as good as it will be is it doesn't account for particle density. So the fact is that you can have a lot of little dense particles, and that's way worse than having 1.2s what's called light, fluffy LDL particles. That's not as bad. So getting the April number tells you the number of particles, which tells you particle density, which tells you more about risk. So when I look at a patient, I really just want to know their April level. Yeah, I'll look at their triglycerides, sure. But it's not. I mean, that tells me something a little bit about their metabolic health, but it's not that interesting. Is not that important in terms of predicting their cardiac risk, if I really want to know how dense. It was slipping particles because dense liquid particles that do the damage right is a little. So like little baseballs. Somebody once wrote that they're like little baseballs being thrown at a window. Right. If you throw a lot of baseballs out the window, you're going to break the glass. And the more part, the more of the baseballs you throw, the more likely you're going to break the glass. If you have light, fluffy particles, they're not like baseballs. They're more like a fluffy 2.2s beach ball, so much less likely to break the glass. If you're if you're smoking, you're throwing stones now. Yeah, they're even denser and they're even worse. Right? So that's kind of how I think about it. So I just want to know the number of of baseballs being thrown in my window. Yeah, no, that makes sense. Just I just want to know my April level and I want to get it as low as possible and however get it down are the most convenient. And for goodness sake, they've been well studied, right? I mean, Sands have been out for like, you know what, 40 years now, 30 years. So we know everything. The good, the bad and the ugly about statins and and they're relatively cheap. They're generic. So you know that's that's your go to. Yeah but if you can't take it no big deal. Yeah. There's some other paths to explore for sure. For sure. So with April be just maybe one step further with that. If someone were to get their apob tested, is there like a magic number that you would suggest it should be under this? And does that number is there like the lower the better? Or is there a point where you said, yeah, going lower than this really doesn't matter anymore? Yeah. So that's great. So. So this seems to show that mean, for example, like human babies have a level, there's like crazy low, it's like 20 or something and they're fine. They, they don't, they're very healthy. They develop normally, their brains grow. They do fine. So low Apob is not bad, right? There's no such thing as too low. Nobody. You get your level down to 20. Congratulations. You're the same as a human baby and you're fine. So it's not like I wouldn't worry about it. The problem is that you're getting to the point that you mention returns, right? You get you start pushing it lower and lower and lower. You start getting side effects of drugs. You start spending money that's not necessary. You get drug interactions, right? Maybe you're taking some other drug and then it interacts with whatever drug you're taking for your cholesterol. And that can be a mess. So, you know, and then what? I try to individualize it like like if you have a 90 year old's, do you really care that there will be a super low? Probably not. It's not going to make a whole lot of difference. But if you have a 20 or 30 year old with a family history or calcium score, that's positive and they have an AP level that's even a little bit elevated, do you really want to jump on that? And you want to make it as low as possible? Because the idea is you want to lower the is. Peter Attia talked about it once, that you really want to lower the area under the curve. Right. You don't want to have high exposure to be over a long period of time. So for younger people, I'm a lot more aggressive. So I want and if the lower like, you know, somebody like you, you came in and you're your young guy and you're exercising a lot, you really don't want to be exposed to a high level of April be for if you're assuming you're going to be live to age 900, we don't want to have you exposed to that for long periods of time. So I would want like you to have an April level of less than 50 for sure. But if you're but if you're a if you're a 70 year old and and you're otherwise pretty healthy, then yeah. I mean, 1.6s if you look at the textbooks, they say the normal April be is less than 90. And I would tolerate that if somebody like, you know, lower risk and they're not going to they're already elderly, then fine, you would settle for an April level of of 80 or 90. It's no big deal factor. You said I would say this, that I don't abandon the elderly at all. Nobody should do that. Mean 1.1s if I have an older patient that's healthy and highly functional, I'm still going to get their April level as low as possible because I don't want them to have a stroke. Right? I mean, I'm talking about. Yeah, I'm not I'm not saying I want them to be an athlete. I just want them to be healthy. I'm going to keep them out of the hospital. And so, sure, I would still treat them, just might not treat them quite as aggressively. Interesting. You know? That all makes sense, David. This has been awesome. I have learned that. I've learned. Learned a bunch and had questions along these these topics of like, I kind of had an idea of where I thought it was going. But it's always nice to have someone come in and kind of point to show exactly where that is. And yeah, I'm sure the listeners are going to love to hear some of this information and start exploring perhaps. But 1.6s other than that, I mean, we'll have to have you come back on down the road when you get pulled out of the lottery for West Ace and going, Oh yeah, sure. It's that epic that. Yeah, that's right. Yeah, that's great. Yeah. Don't think there are a lot of cardiologists qualifying for western states, so kind of an odd, odd breed there. Yeah. Yeah. No you'll, you'll be, I'm sure one of few if any. So that'll be, that'll be fun. Awesome. David, do you want to share with the listeners where they can find you? Are you on the Internet anywhere. So one of the I'm on the yeah. Do social media among Twitter and threads on Facebook and I see patients and I'd love to see endurance athletes or ultra runners have a few things that have come in and that's really fun so yeah mean I'm happy to see people who aren't even sick. I mean, I'm happy to talk about like risk reduction instead of just illness. That's always a fun change for me. Yeah, Yeah. Up in Eugene. 1.1s In Eugene, Oregon. Yeah. Well, Andreas here does your business to only in person stuff or do you have any sort of online type of stuff that people. Wow. At present? No, it's not my business. I'm employed by a big hospital. Oh, okay. Gotcha. I'm so. It's a big it's a big, um, a health system here in the Pacific Northwest. So I work for them, but I see patients and you can find me online and go through that way. But no, don't do remote stuff. Now that has kind of died down. Don't do that right presently, but could think about it in the future. It's a good idea. I'm just imagining all these alternatives. Looking for your consultation? Yeah. 1.4s Oh, 1.6s man. No. Oh, no. Dave, it's been great to have you on. Thanks a bunch for giving me some of your time today and have a great rest of the day. Well, thank you very much.