So I warned you before we go there. This one's gonna be a little bit geeky G E E K Y
geeky. We're gonna get deep into an article but for those of you a lot of
you have interests in it and I think it'll help you connect some dots, help
you stand with one foot in the new YouTube prevention, keto world, low-carb
insulin-resistant world, and another foot in terms of understanding the old
standards of medicine, how they are progressing, how they're beginning to
understand some things like triglyceride rich lipoproteins TG-LP or what others
of us might call "remnant cholesterol."
So this was a this is an article in JACC - Journal of the American College of
Cardiology. "Triglycerides, Remnant Cholesterol and Atherosclerotic
Cardiovascular Disease." Interesting the way they kicked it off. They said you
know what we know that LDL is a big risk factor; however, as we continue to get LDL
out of the way, there's still a lot of risk there. Mmm, no comment. Then they go
on to say TGRL (triglyceride-rich lipoproteins or remnant cholesterol) may
be an important contributor to residual risk. There there are a couple different
kinds. One is chylomicrons. Chylomicrons are the lipid lipoproteins that
come from a triglyceride-rich diet, so they're coming from the intestines
after a meal with a lot of lipids in it or a lot of triglycerides in it. VLDL,
well, VLDL are very low density lipoproteins. They're made by the liver.
Then you have IDL which is intermediate medium-density lipoproteins.
LDL and HDL... LDL and HDL. as we know about. Again, these big ones with a lot of
triglyceride on them are known as remnant cholesterol. If the term "remnant
cholesterol" rings the bell for you in terms of the YouTube world, yep, you see
it with Dave Feldman's doing a lot of stuff. He's all over a low-carb down
under, and again here's why there's the that connection there. It's pretty clear
that one of the major ways of decreasing triglycerides (whether they're VLDL,
remnant cholesterol, or just triglycerides in your triglyceride... the
the standard triglyceride in the cholesterol panel)... one of the best ways
to do that is cut the carbs out of your diet. So let's go back to the article in
terms of epidemiology.They're saying the the pendulum has swung to focus more on
triglycerides, triglyceride-rich lipoproteins, and remnant cholesterol. Now
when they're talking about this pendulum having swung, they're talking about... okay...
LDL, and then maybe focus on niacin. Then they talked a little bit about niacin
and some challenges with AIM-HIGH and HPS2-THRIVE. Still, we're not gonna... I've
covered that in-depth in other videos on niacin.
(I still use up niacin by the way, and I still recommend it.) And they get into
some detail a little bit later about why that's that might actually be a good
idea. Now then they go on, and they say, well, it's not really that simple. When
you look at ARIC (Atherosclerotic Risk in Communities) cohort, remnant
cholesterol was shown to correlate with cardiovascular disease. However, after you
started adjusting it for other things, like HDL, in other words, a low HDL is
going to increase your risk than intended to wash out that risk. Well I
mean think about it. If your HDL is decreasing, we know HDL
decreases as triglycerides go up. So you're taking a lot of this the same
components out of the equation for the research. Anyhow, they went on to talk
about Jackson Heart and Framingham Offspring Cohort studies, other ones
which started to again help remnant cholesterol emerge as maybe an issue
after all. So again, from what they're seeing... the way the lens that they are
looking through... there may be an issue there. Now if you look at the genetic
studies... I'm gonna remind you something that's a little bit mind-bending, don't
get too wrapped around your axial on it... it's called Mendelian randomization. It's
basically looking at genetic studies. And here's the thing. Once we realize
that with Mendelian randomization (in other words, basic genetics), we're going
to have random randomized distribution of genes. You can begin to actually tease
out potential causality when there's a relationship between the potential cause
and the disease. So in this case, the short story is this, in this case when
you start looking at triglycerides and remnant cholesterol and using Mendelian
randomization methods, it begins to start looking again like high triglycerides
might cause heart attack and stroke. Well again, it's impressive that we're finding
that out, isn't it? So then they go into the pharmacology. Lifestyle modifications
are the foundation for management. Isn't that nice that they said that, and it is
true you tend to we tend to think that the standard physicians neglect things
like lifestyle. The reality is it depends on how you look at it now. You could say
that they're neglecting it in this article. They're really not. They start
off with a statement of look lifestyles the standard of the foundation for
management. In fact, lifestyle will manage 60% of triglyceride, hypertriglyceridemia or
increased remnant cholesterol or an elevated triglyceride over HDL or
whatever else you are tending to call this. Because this is written by doctors
for doctors. However, they start to get deeper into more details of what only
doctors are going to be doing and that is prescription medications. So yes, I
mean I know I've been guilty of this too, beating up on other docs for not
focusing enough on lifestyle. It just happens.
Let's move on. So with regards to pharmacology management,
drugs can lower this another significant 20% another 22 to 45%. Now
currently in terms of prescription drugs, there are three kinds of classes and one
of them is actually both prescription and non-prescription: the fibrates, the
niacins, and the omega 3 fatty acids. Let me go back and correct what I said. One
of them is both prescription and non-prescription. Actually, two of those
classes: the niacin class and the omega-3 class because there are both
prescription and non-prescription levels. Note of niacin - Niaspan versus Endur-acin
Oral. And don't and please avoid the others, and I have no financial
relationship or anything else with those two that I mentioned. And omega 3 fatty
acids. With omega-3 fatty acids, you can go from all kinds of supplements to the
newest latest and greatest (eicosapent ethyl).
So triglycerides and fibrates. Fibrates or fibric acid derivatives exert their
lipid-modifying effect by... there's a big long bunch of words here... peroxisome
proliferator-activated receptor. Those of you who remember you, may remember it as
PPAR PPAR alpha P bar gamma. It's a nuclear receptor. It increases expression
of several related genes involved in metabolizing lipoproteins.
Well, Helsinki Heart Study, the Veterans Heart Study, others saw a decrease in in
cardiovascular disease but no decrease in mortality. Again, remember that's
probably still means that it works. Decreasing in mortality means there's
got to be you know mortality it's important as heart attack and stroke risk is. It's
still only a third of deaths. So fibrates, yes, they help, They can be
difficult, they can be challenging to take in terms of side effects and side
reactions. Omega 3's, as I mentioned, there's been several studies that have
focused on this. The JELIS study (the Japan EPA Lipid Intervention Study) was
originally looking some statins like pravastatin and simvastatin. But in
conjunction with EPA, a statistically significant improvement in
cardiovascular disease. The STRENGTH study is currently ongoing. And guess
what? The REDUCE-IT study, yes, just came out earlier late last year... earlier this
year... 25% decrease in major cardiovascular
events. So again, yes, these things do work and again those are omega 3s or what
many people know as fish oils and krill oils and some of the other sources. We
mentioned triglycerides and niacin a couple of times already. And I've already
as I said I've covered AIM-HIGH and HPS2-THRIVE in other videos. These
bottom line again, there was an improvement in the biomarkers
in those two studies alone. They did not see a decrease in heart attack and
stroke It was a big surprise everybody wanted to throw nice and out and throw a
niacin out for example along with the pro prion variant alig astir throwing
the baby out with the bathwater. If you get as they mentioned here, as you get
deeper in terms of the analysis and sub analyses, it goes back and shows that yes
you do get do get a decrease in cardiovascular cardiovascular risk.
So again, got pretty deep, pretty geeky, and pretty long. For those of you that
have made it this far, gosh, I'm impressed, and thank you
very much. If plaque is the number one cause of heart attack,
stroke, dementia, blindness, kidney disease, you think we'd know how to evaluate it,
screen for it. Unfortunately, the state of the art right now is a guess
and a bad one at that - Framingham. The most common thing that
you do is you say, well, hey Doc, why don't we do a stress test. They don't work
either. Then you go into the cath lab and get a definitive test. But that revolves
getting a needle in the groin. It just goes downhill from there. Now
there are better ways. Take a look at our plaque evaluation course. Click the link
below.