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In this episode, Ethan Weiss, preventative cardiologist at UCSF, compares & contrasts the diagnostic imaging tools, CAC (coronary artery calcium score) & CTA (CT angiography), used to image plaque & how these tools inform our understanding of ASCVD risk & guide clinical decision-making. He discusses the types of plaque that cause events & the data that make a case for optimal medical therapy over stenting outside of particular cases. He explains why high blood pressure is problematic & walks through the data from clinical trials testing aggressive treatment. He talks about the best way to measure blood pressure, why we shouldn’t simply accept that blood pressure rises with age, & how he uses different drugs to treat hypertension. Additionally, he explains our current, but limited, understanding of the role of metabolic health in ASCVD. He discusses the impact of fat storage capacity/location & explains how & why there is still a residual risk, even in people who have normal lipids and blood pressure.

We discuss:
0:00:00 - Intro
0:00:08 - Ethan’s entrepreneurial work in the cardiometabolic disease space
0:02:03 - Calcium scans (CAC scores) & CT angiography (CTA), & how it informs us about ASCVD risk
0:07:15 - Peter’s historical CAC scores, CTA results, & how one can be misled
0:12:07 - How Peter’s CTA results prompted him to lower his apoB
0:19:39 - Calcium scans vs. CT angiogram (CTA)
0:28:07 - How Ethan makes clinical decisions based on CTA results & plaque burden, & the importance of starting treatment early to prevent ASCVD
0:34:12 - Improved methods of CTA to grade plaque lesions & how it’s shaped medical decisions such as stenting
0:43:31 - Why Ethan favors optimal medical therapy over stenting outside of particular situations
0:57:23 - The need for FFR CTA, & the potential for medical therapy to eliminate ASCVD
1:01:31 - The fat attenuation index (FAI) & other ways to measure inflammation in a plaque
1:04:00 - Statins & exercise may increase the risk of calcification, but what does this mean for risk?
1:10:54 - The root cause of statin hesitation
1:17:07 - Importance of keeping blood pressure in check, defining what’s normal, & whether we should just accept higher blood pressure with age
1:28:59 - Blood pressure variability, how to best measure it, & data suggesting the enormous impact of keeping blood pressure down
1:45:05 - Drugs for treating high blood pressure recommended by the ALLHAT trial
1:48:27 - What the SPRINT trial says about the aggressive treatment of hypertension, & the risks of such treatment
1:54:04 - Confirmatory results in the STEP trial for blood pressure, & how Ethan uses the various drugs to lower blood pressure in patients
2:03:06 - The role metabolic health in ASCVD
2:08:50 - The impact of fat storage capacity & location on metabolic health & CAD

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About:

The Peter Attia Drive is a weekly, ultra-deep-dive podcast focusing on maximizing health, longevity, critical thinking…& a few other things. With over 45 million episodes downloaded, it features topics including fasting, ketosis, Alzheimer’s disease, cancer, mental health, & much more.

Peter is a physician focusing on the applied science of longevity. His practice deals extensively with nutritional interventions, exercise physiology, sleep physiology, emotional & mental health, & pharmacology to increase lifespan (delay the onset of chronic disease), while simultaneously improving healthspan (quality of life).

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