#185 - Allan Sniderman, M.D.: Cardiovascular disease and why we should change the way we assess risk

The Peter Attia Drive

Allan Sniderman is a highly acclaimed Professor of Cardiology and Medicine at McGill University and a foremost expert in cardiovascular disease (CVD). In this episode, Allan explains the many risk factors used to predict atherosclerosis, including triglycerides, cholesterol, and lipoproteins, and he makes the case for apoB as a superior metric that is currently being underutilized. Allan expresses his frustration with the current scientific climate and its emphasis on consensus and unanimity over encouraging multiple viewpoints, thus holding back the advancement of metrics like apoB for assessing CVD risk, treatment, and prevention strategies. Finally, Allan illuminates his research that led to his 30-year causal model of risk and explains the potentially life-saving advantages of early intervention for the prevention of future disease. We discuss:

• Problems with the current 10-year risk assessment of cardiovascular disease (CVD) and the implications for prevention [4:30];
• A primer on cholesterol, apoB, and plasma lipoproteins [16:30];
• Pathophysiology of CVD and the impact of particle cholesterol concentration vs. number of particles [23:45];
• Limitations of standard blood panels [29:00];
• Remnant type III hyperlipoproteinemia—high cholesterol, low Apo B, high triglyceride [32:15];
• Using apoB to estimate risk of CVD [37:30];
• How Mendelian randomization is bolstering the case for ApoB as the superior metric for risk prediction [40:45];
• Hypertension and CVD risk [49:15];
• Factors influencing the decision to begin preventative intervention for CVD [58:30];
• Using the coronary artery calcium (CAC) score as a predictive tool [1:03:15];
• The challenge of motivating individuals to take early interventions [1:12:30];
• How medical advancement is hindered by the lack of critical thinking once a “consensus” is reached [1:15:15];
• PSK9 inhibitors and familial hypercholesterolemia: two examples of complex topics with differing interpretations of the science [1:20:45];
• Defining risk and uncertainty in the guidelines [1:26:00];
• Making clinical decisions in the face of uncertainty [1:31:00];
• How the emphasis on consensus and unanimity has become a crucial weakness for science and medicine [1:35:45];
• Factors holding back the advancement of apoB for assessing CVD risk, treatment, and prevention strategies [1:41:45];
• Advantages of a 30-year risk assessment and early intervention [1:50:30];
• More.

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