[carbocation]

    Key Takeaway: Get a CT or CTA scan, and if you can afford it go for the CTA with Cleerly.

There is a reason that we don't recommend getting imaging for everyone, and that reason is uncertainty about the benefit vs the risks (cost, incidentalomas, radiation, etc, all generally minor). Most guidance recommends calcium scoring for people with intermediate risk who prefer to avoid taking statins. This is not a normative statement that is meant to last the test of time: it may well be the case that these tests are valuable for a broader population, but the data haven't really caught up to this viewpoint yet.

[safety1st]

Right.

Hang on a second.

This guy is making a big big claim.

The central point of his article is that he went to a doctor who followed the guidelines, tested him and found he wasn't at risk for heart disease.

But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.

Therefore he is arguing that THE STANDARD GUIDELINES ARE WRONG AND EVEN IF YOU DO EVERYTHING RIGHT AND YOUR DOCTOR CONFIRMS IT YOU MAY BE LIKELY TO DIE OF HEART DISEASE ANYWAY, SO ONLY THE SPECIAL EXTRA TESTS CAN REVEAL THE TRUTH.

I want a second opinion from a doctor. Is this true? Is this for real? Because it smells funny.

[Apes]

I strongly suspect the truth is both are "right", but they're both optimized answers to slightly different problems.

Mainstream medicine is hyper optimized for the most common 80% of cases. At a glance it makes sense: optimize for the common case. Theres some flaws in this logic though - the most common 80% also conveniently overlaps heavily with the easiest 80%. If most of the problems in that 80% solve themselves, then what actual value is provided by a medical system hyper focused on solving non-problems? The real value from the medical system isnt telling people "it's probably just a flu, let's just give it a few days and see" it's providing a diagnosis for a difficult to identify condition.

So if your question is "how do we maximize value and profit in aggregate for providing medical care to large groups of people", mainstream medicine is maybe a good answer.

But if your question is "how do we provide the best care to individual patients" then mainstream medicine has significant problems.

[fwip]

Part of providing good care is not burdening the patient with tests or treatments that are very unlikely to yield benefit. Put another way, the mission of healthcare is not "health at any cost."

[embedding-shape]

The mission of healthcare in the eyes of those who provide it, isn't "health at any cost".

For the people on the other side, "health at any cost" is pretty much the goal, usually limited by the "cost" side of things, especially in the parts of the world where they haven't yet figured out the whole "healthcare for the public" thing.

[fwip]

Cost here doesn't just include financial cost, but also time. As an extreme example, you could surely catch diseases earlier by visiting a doctor for an hour or two every day - getting tests for all sorts of things you might have conceivably developed. But that would make your life worse, and so most people wouldn't do that even if it was free.

[6510]

The actual question should be "how do we have the fewest patients"

[cthalupa]

The National Lipid Association and American Heart Association have both been advocating that lower cholesterol numbers are better, e.g. https://www.lipidjournal.com/article/S1933-2874(25)00317-4/f...

Research science in this area has been in agreement for a long time now that ApoB is a more informative indicator than just LDL-C, because there are a variety of different atherogenic particles, not all LDL particles are created the same, etc.

His ApoB numbers are quite readily and apparently out of range. Hell, even his LDL is out of range for the two largest lab providers in the US - Labcorp and Quest both have <100 for their reference range. But the science shows that plaque progression is still generally occurring at levels above 70 LDL-C even with low Lp(a) and other atherogenic particles - the reference ranges are likely to get moved lower and lower as practice catches up with research.

His numbers are well within the range of concern based on pretty universal consensus across the research in this area over the past couple of decades. Preventative cardiologists and lipidologists would almost certainly agree with this concierge doctor.

[safety1st]

Thanks for the astute and informed comment. So re-reading that portion of the article, it seems to me the answer to my question is not that any general or consensus guidelines are wrong, but that a company called Forward Health is doing lipid panels and providing an incorrect interpretation of the results.

OP's LDL-C was 116 and this is on the very top end of what Forward Health's report says is OK, their report is wrong, this number is bad.

All the stuff about needing to measure ApoB, needing a high end concierge doctor, and the very long article about measuring 10-20 different numbers and doing more exercise than the guidelines and being at risk of heart attack if you don't do amounts of exercise that the author consider unreasonable etc., some of this may have value, but this all seems to be a lot of very lengthy personal opinion by the techbro author of the post. The key insight is simply that your LDL-C becomes a cause for concern over 100, perhaps even over 70, and he was not as healthy as some tech company told him he was. No surprise there, I will talk to actual doctors instead of using services from "tech forward" startups any day of the week.

[cthalupa]

I would agree that this article overstates a lot of things.

ApoB is still a reasonable thing to check though, at least once - Lp(a) is the primary cause of atherogenic particle counts being high when LDL-C isn't the culprit, and it's usually a genetic factor. Having a high Lp(a) will bounce your ApoB up and give you a better understanding of the total atherogenic particle load. You could have fine LDL-C or Lp(a) on their own but the total amount could be enough to be worrisome.

Lp(a) being problematic is definitely less common than it being more or less fine, but it's certainly not incredibly rare, either.

[safety1st]

Really great context, thanks!

[carbocation]

The claim on an individual level is not objectionable to me. The question is that if we extrapolate it out to the population and actually take this action for everyone, do we make people better off? This is what clinical trials (or at least large observational studies) try to achieve. Right now, it is not clear.

[malfist]

His evidence is also kinda weak. And appeal to authority largely about someone who he's paying to tell him he has health problems. The incentives aren't aligned.

I also disagree that the 50the percentile is the breakpoint between healthy and unhealthy. There's a lot more to deciding those ranges beside "well half of the population has better numbers"

[kelipso]

ApoB is a better indicator of heart problems and his ApoB was bad, unlike his LDL-C. ApoB is not some imaginary thing made up by a quack doctor.

[cthalupa]

Even his LDL-C is bad. 116/119 are both out of range by most lab testing standards and the top end of range already allows for plaque deposition.

[kelipso]

That LDL-C is considered normal, what are you talking about. 160 is when doctors start being concerned.

[cthalupa]

That is an out of range value for the two largest testing labs in the USA - Quest and Labcorp. Their upper end is 100.

https://testdirectory.questdiagnostics.com/test/test-detail/...

https://www.labcorp.com/tests/120295/low-density-lipoprotein...

If you think a 100+ LDL-C is normal you're basing things off of significantly outdated information.

Expect the normal range to drop in the coming years as well - the AHA and NLA have both been talking about how this needs to go lower, and the science is robust. See my other comments for study links, the NLA's latest guidance, etc.

If your doctor is only getting concerned at 160+, find a new doctor.

[wrs]

You may have missed the stat that 30% of the population that’s the median of will die of heart disease. You don’t want to be at the median.

[rgmerk]

100% of the population will die of something.

If I die at 90 of a heart attack havjng maintained the ability to live independently up until then, I’d take that as a massive win compared to my relatives suffering through a decade of me with worsening dementia.

[ac29]

Cardiovascular diseases are huge risk factors for dementia, so if your goal is to avoid dementia you should try to have a healthy cardiovascular system.

[malfist]

If health science was as simple as health outcomes are proportional to one or two measurement percentiles, sure. But that's hardly true. Health is a lot more complex than that and the disease risk cannot be quantified by a small number of parameters

[bsder]

The plural of anecdote is not data.

Maybe he got missed--let's concede that. What about the other 10 or 100 or 1000 or subjected themselves to tests and didn't find anything? Where are their stories?

If you have enough people, the tests, themselves are eventually going to harm somebody.

For example, certain scans require contrasts like gadolinium that bioaccumulates. That's not a big deal if we only pump it into people 2 or 3 times in their lives when something in their body is about to explode. It's a lot bigger deal if we're doing that to them every year.

[antonvs]

We went through this with Oprah in 2007. She did a show about her CT scan and how wonderful it was.

Here's what the New York Times had to say about it the following year: https://www.nytimes.com/2008/06/29/business/29scan.html

The bottom line is these tests aren't some sort of one-size-fits-all panacea, and nor can they perfectly predict the future. In fact Oprah herself backtracked on it, via an article by Dr. Oz in her magazine in 2011: https://www.oprah.com/health/are-x-rays-and-ct-scans-safe-ra...

A good rule of thumb is don't take medical advice from Oprah or Dr. Oz. But in the case of the latter article, he wasn't wrong.

[Aurornis]

> But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.

It’s scarily common in medicine for doctors to start specializing in diagnosing certain conditions with non-traditional testing, which leads them to abnormally high diagnosis rates.

It happens in every hot topic diagnosis:

When sleep apnea was trending, a doctor in my area opened her own sleep lab that would diagnose nearly everyone who attended with apnea. Patients who were apnea negative at standard labs would go there and be diagnosed as having apnea every time. Some patients liked this because they became convinced they had apnea and frustrated that their traditional labs kept coming back negative, so they could go here and get a positive diagnosis. Every time.

In the world of Internet Lyme disease there’s a belief that a lot of people have hidden Lyme infections that don’t appear on the gold standard lab tests. Several labs have introduced “alternate” tests which come back positive for most people. You can look up doctors on the internet who will use these labs (cash pay, of course) and you’re almost guaranteed to get a positive result. If you don’t get a positive result the first time, the advice is to do it again because it might come back positive the second time. Anyone who goes to these doctors or uses this lab company is basically guaranteed a positive result.

MCAS is a hot topic on TikTok where influencers will tell you it explains everything wrong with you. You can find a self-described MCAS physician (not an actual specialist) in online directories who will use non-standard tests on you that always come back positive. Actual MCAS specialists won’t even take your referral from these doctors because they’re overwhelmed with false cases coming from the few doctors capitalizing on a TikTok trend.

The same thing is starting to happen with CVD risks. It’s trendy to specialize in concierge medicine where the doctor will run dozens of obscure biomarkers and then “discover” that one of them is high (potentially according to their own definition of too high). Now this doctor has saved your life in a way that normal doctors failed you, so you recommend the doctor to all of your friends and family. Instant flywheel for new clients.

I don’t know where this author’s doctor fits into this, but it’s good to be skeptical of doctors who claim to be able to find conditions that other doctors are unable to see. If the only result is someone eating healthier and exercising more then the consequences aren’t so bad, but some of these cases can turn obsessive where the patient starts self-medicating in ways that might be net negative because they think they need to treat this hard to diagnose condition that only they and their chosen doctor understand.

[rasse]

It's important to note that there's geographic variability in guidelines. Also, the article doesn't give enough information about the author's other risk factors. For a similar patient (based on the initial lab results), treated by a doctor adhering to the European guidelines, at least the following items would have been considered:

- Lipid lowering drugs

- ApoB testing

- Coronary CT (if the pre-test likelihood of obstructive coronary artery disease was estimated to be > 5%)

- Diabetes tests

- Kidney tests

[sixtyj]

If there are two contradictory conclusions you should ask for the third one, independent on the previous ones.

[Apes]

The year is 1846, and a doctor has a radical new idea: doctors should wash their hands between performing autopsies and delivering babies!

You're not sure of whether this is a good idea or not, so you ask various physicians, and the consensus is unanimous: the very suggestion is offensive, do you think doctors are unclean?

A clear conclusion has been achieved.

[paxys]

Are you implying that every new, unproven idea is a good one?

[sixtyj]

You’re right. My comment doesn’t make sense.

[IshKebab]

That seems like a super dumb reason to me. "We don't look because we might misinterpret the results"?? Fix the interpretation then!

It's crazy that we haven't optimised MRI scans so that they can be routine.

[ozozozd]

Not sure I follow or maybe you skipped typing a word.

You listed the risks and concluded “all generally minor.” The benefit is absolutely nonzero. So, what’s the hold up?

And how have the data not caught up? People outside the US are getting the CT scans, while US doctors prefer to lick their finger to guess the weather.

My wife’s last interaction with a doctor: patient presents with back and chest pain accompanied by occasional shortness of breath at the age of 39, doctor reluctantly asks for a EKG - which takes 5-10 minutes and is done in the next room, right away and covered by insurance with a small copay - and has the gall to be surprised when EKG showed subtle abnormalities. If she hadn’t advocated for herself, as the OP argues, doctor would just skip the EKG.

This experience left me thinking maybe doctors are discouraged from asking for imaging and guidelines are there to protect their criminally negligent behavior. I have no proof or even proxy data for the claim about doctors being discouraged from asking for imaging. But it is objectively criminally negligent to not ask for imaging in a case like this.

[moralestapia]

"Smaht" people continuously parrot things they read elsewhere, usually in a contrarian way, to assert themselves in a futile and shallow way.

There is absolutely nothing wrong with getting one CT at a specific point in your life to right a disease which, as TFA states, has a 25% incidence rate.

The smaht ones will now point me to that study of 1-5% of cancers being linked to CT scans. Yeah, sure, but those are not from people who got one-two in their lives.

[jbritton]

A CIMT scan is another option. It uses ultrasound to measure carotid artery wall thickness.