Don't Die of Heart Disease

During my "hiatus" I've been doing research in a variety of different areas that interest me. After a personal experience with basal cell carcinoma that set me on a journey to better understand and take control of my own health, I ended up going deep on heart disease prevention. My father is a cardiologist and his mantra has always been that heart disease is entirely preventable. Nobody needs to die of it, so long as they know how not to.

Heart disease is the world's biggest health problem. It's the leading cause of death globally for both men and women.

It's not just an old-people problem. 25% of heart attacks occur in people younger than 54 years of age. That percentage continues to grow over time as the general population becomes increasingly less healthy (ie sedentary, obese, poor-diet, etc.). For all the damage heart disease inflicts on people's lives and our health systems, it receives very little attention. Take a look at how frequently population killers are covered by the media:

It's not sexy, and as a result an overwhelming majority of the population is unaware about how to avoid succumbing to it.

The thing about heart disease is that we have all the tools to make it a nonentity and remove it entirely from the Top 10 leading causes of death. Unfortunately, for a whole host of reason, our primary care physicians are neither equipped or incentivized to lead the charge on fixing the problem. More often than not the first sign that someone has heart disease is they drop dead of a heart attack. And by the time fortunate patients who don't drop dead approach their doctor about chest pain and are referred to a cardiologist, that cardiologist is going to wish you had visited them five years ago. It's a disease that slowly builds over decades, so the best way to really avoid dying from it is to start getting educated and taking action in your late 20s, 30s, and 40s.

Over the past several months I've spoken with several of the world's leading cardiologists and lipidologists to better understand the key elements of heart disease prevention. I've been compiling notes to get to the lowest common denominator of what is good enough (definitely not perfect!) and affordable so I can arm friends and family with the information and steps to put their heart health in their own hands. I've found that the steps/protocol for avoiding death by heart disease are very simple. Go visit your PCP and ask for the following:

  • Test 1: An expanded lipid panel, ideally from the Cleveland Heartlab (owned by Quest). Occasionaly, if you go for a physical, your doctor will do a standard lipid panel which covers basics like LDL-C and HDL. But the biomarkers that are most important are ApoB, Lp(a) (a critical one-time measure), and hsCRP. These are only measured in an expanded lipid panel which costs an incremental $20-90. Every lipidologist I've spoken with has stressed the importance of measuring and managing ApoB above all else - it's a far better predictor of cardiovascular disease than LDL-C. Every standard deviation increase of ApoB raises the risk of myocardial infarction by 38%. Yet because guidelines regularly lag science by 15-20 years, the AHA still recommends LDL-C over ApoB. Test for it regularly (ideally twice a year) and work to get it as low as possible. Many lipidologists will say to focus on this above all else.

  • Test 2: Lipidologists focus on understanding biomarkers and managing them as much as possible. Cardiologists care about understanding the state of disease and treating it. Every cardiologist I've spoken with recommends getting your calcium score either through a basic CT scan (which costs roughly $150 out of pocket unless your doctor is savvy enough to navigate insurance) or a CTA scan, ideally one with Cleerly imaging (these cost more - anywhere between $1-1.5k). Your calcium score will tell you how much calcified plaque you have in your arteries. This is heart disease (ie atherosclerosis). Everyone accumulates plaque as they age. You don't want any more of it. When plaque begins to form it is noncalcified "soft plaque" - this is the stuff that breaks free from your artery walls and creates a clot that leads to a heart attack or stroke. Calcium scores measure calcified or "hard" plaque, the stuff soft plaque turns into. It's a proxy for how much plaque you're accumulating. CT scans will tell you this. A CTA will measure both hard and soft plaque and the Cleerly scan will give you a 3D visualization of your arteries, tell you where the plaque exists, and how much and what kind there is. At the bare minimum get a CT scan. Depending on these diagnostic results, you'll need to repeat this test once every 1-5 years depending on the state of disease. The same way you get a colonoscopy at regular intervals to detect colon cancer and other disease, you should do this, too.

You'll likely need to demand these tests from your PCP. Physicians (and our medical system writ large) are disincentivized from helping you prevent disease. You need to be your own advocate on your health journey and know what to ask for. If they ask you why, just say you have a history of heart disease (you likely do), or just tell them that you want to know your biomarkers better and whether or not you have disease. Take the results of these tests and bring them to your PCP or a cardiologist for interpretation.


  • Between medication and knowledge about how to prevent or mitigate heart disease, we have all the requisite tools at our disposal to beat the thing. Statins or PCSK9 inhibitors help to lower ApoB concentrations and do miracles for lipid management. Some people have adverse reactions to statins, but there are substitutes for them. I'm on a statin. Pretty much everyone should be on one so long as they don't have adverse side effects. ACE inhibitors will help to manage blood pressure if you have high blood pressure (another thing your PCP will test for). Baby aspirin will help with blood thinning and reduce blood clots. In Europe there is a polypill that combines these three drugs and has had an extremely positive impact. There are also new medications like colchicine to help manage inflammation. Ask your doctor or cardiologist about all of these and whether they're right for you.

  • We can't medicate heart disease out of existence yet. Behavioral changes are also required. This means regular exercise (both strength training ideally 3x per week and cardio training that helps to improve V02 max like Zone 2 training). It also means diet. Sticking to a Mediterranean diet that is light on carbs and grains is almost always the safest bet. Most every health diet is some permutation of this. Also, if you smoke, stop yesterday.

These treatments go after the core of what Jeffrey Wessler, Founder and CEO of Heartbeat Health, succinctly summarizes: "Coronary artery disease occurs when circulating fats in the blood (lipids) are pushed by a driving force (blood pressure) into a vessel wall that is vulnerable (endothelial dysfunction)." Both medication and behavioral interventions are not one-time events - they're for life. But every single lipidologist and cardiologist I've spoken with unanimously agree that for almost everyone (unless you are an edge case or severely meaningfully diseased already) this will do the trick - you can die of something else, just not heart disease.

These tests and medications have existed for a long time. They're tools that are readily available at our disposal, but you have to ask for them. They are not prescribed unless you are sick. And unfortunately, when it comes to heart disease being sick sometimes means being dead. It takes effort to prevent this. Like many things, the biggest hurdles are knowledge and willpower. My hope is that the knowledge becomes pervasive, that accessing these diagnostics and treatments becomes easy, cheap, and ubiquitous (they pretty much already are), and that people are motivated enough to be their own advocates and take their health into their own hands and make the conscious decision to not die of heart disease.

*If you do this, I'd appreciate if you'd share with me your PCP's reaction. I'd also like to understand why you wouldn't pursue this course of action. I'm

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