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Short Summary
Main recommendation: Address inflammation and apolipoprotein B (ApoB) and get specific tests beyond the standard annual checkup, because normal cholesterol does not rule out heart attack risk. Dr. Leonid Kim says high sensitivity CRP (hsCRP), ApoB, lipoprotein(a), and fasting insulin reveal hidden risk that a routine panel and 10-year risk calculator often miss.
Key Points
- The CANTOS trial showed that lowering inflammation without changing cholesterol cut major cardiovascular events by 15%, and by 25% in patients whose hsCRP fell below 2.
- A larger collaborative analysis of over 31,000 patients already on statins found that those with hsCRP above 2 had double the cardiovascular death risk of those with low inflammation.
- Standard LDL can look normal while ApoB stays high, especially with insulin resistance, because ApoB counts every atherogenic particle (LDL, IDL, VLDL).
- Dr. Kim says plaque develops over decades starting in adolescence, so he believes the 10-year ASCVD risk calculator tends to flag danger too late.
- Elevated lipoprotein(a), a largely genetic marker carried by about one in five people, can double or triple heart attack risk and is not on standard panels.
- Dr. Kim says insulin resistance may be a bigger driver of heart disease than cholesterol; he cites the Quebec Cardiovascular Study, where people with high insulin had more than five times the heart disease risk.
Details Worth Noting
- Concrete instructions:
- Ask your doctor to check hsCRP and trend it over time; if elevated, look for root causes such as excess visceral fat, insulin resistance, poor sleep, chronic stress, or untreated dental issues.
- Ask for an ApoB test. Dr. Kim's personal target for patients is below roughly 60 mg/dL (the fifth percentile), and if only LDL is available, he suggests aiming for LDL below 60 or 70 mg/dL, while noting this is more aggressive than typical guidelines.
- Ask for a one-time lipoprotein(a) test; the American Heart Association recommends all adults get it checked at least once.
- Ask for fasting insulin alongside fasting glucose and A1C. High insulin with normal glucose means the pancreas is compensating.
- To address insulin resistance, the speaker names these levers: reduce visceral fat, combine regular aerobic and resistance training, and cut refined carbohydrates and ultra-processed foods.
- Imaging such as coronary artery calcium (CAC) scoring, coronary CT angiography, or carotid intima-media thickness (CIMT) ultrasound shows whether plaque has already started; the speaker says a dedicated video on these is forthcoming.
- Lp(a) has an extra protein wrapped around LDL-like particles, which accelerates plaque and clot formation and can cause calcium buildup on the aortic valve (aortic stenosis).
- No FDA-approved Lp(a) medication exists yet, though the speaker says several therapies are in phase three trials.
- Insulin resistance can hide behind normal fasting glucose and A1C results, and Dr. Kim says it is often reversible when caught early.
- The speaker states he is a physician but not the viewer's physician and that the video is educational, not medical advice; consult a doctor before changing your regimen.
Bottom Line
Standard checkups can miss the early drivers of heart disease, so the useful next step is to request hsCRP, ApoB, lipoprotein(a), and fasting insulin testing and discuss the results with your doctor.
