Allan Sniderman, M.D.: Cardiovascular disease and why we should change the way we assess risk

**Peter Attia** (0:11)
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Now, without further delay, here's today's episode.
My guest this week is Dr. Allan Sniderman. Allan is a senior scientist at the Research Institute of McGill University Health Center and the Edwards Professor of Cardiology and Professor of Medicine at McGill University. He's the director of the Mike Rosenblum Laboratory for Cardiovascular Research at Royal Victoria Hospital in Montreal, and he was elected a fellow of the Royal Society of Canada in 2009 He's also been an enormous mentor of mine for the past 10 years, certainly one of the three or four people I would count that has nearly single-handedly provided me with the education that I try to use today to help understand cardiovascular disease. A number of you may recognize the name Allan. I've certainly included him in some of the things I've written about, and also he's been mentioned a number of times on previous podcasts featuring no less than Tom Dayspring and Ron Krauss. His memberships are probably too numerous to mention, but a few of them include the Royal College of Physicians and Surgeons in Canada, the American College of Cardiology, the American College of Physicians, the Canadian Cardiovascular Society, the American Society for Clinical Investigation, the American Federation for Clinical Research, and a number of others. Okay, this is a bit of a complicated topic. We go very deep on cardiovascular medicine and we actually start this podcast not in a way that I intended to because in the first 10 or 15 minutes, Allan lays out some of the most clear complex, and you might say, well, how can those be used the same? But what I mean is clear thinking of complex concepts that you'll ever hear anybody talk about with respect to ApoB and risk management.
It becomes clear to me as I get engulfed in that discussion that I need to back this way up so that everyone listening to this who doesn't already find themselves steeped in that literature can orient themselves. So my first comment here is don't be dissuaded by how complicated the first 10 or 15 minutes of this podcast is.
Instead, just try to sit tight and we'll walk you through the journey of what ApoB is and why it is a superior metric for predicting risk of atherosclerosis relative to the far more commonly used metric LDL cholesterol and the metric that is better than LDL cholesterol but still inferior to ApoB, which is non-HDL cholesterol. We also go into great detail about the role of triglycerides, HDL cholesterol, total cholesterol, et cetera, in the understanding of and prediction of cardiovascular disease. We get into some of the interesting exceptions, i.e. disease states where not knowing ApoB poses an enormous blind spot. And we talk about the challenges that face people like Allan as they try to disseminate the most leading edge and cutting edge science on this topic in an environment that is really wed to guidelines and consensus-based recommendations that don't necessarily incorporate all of the best evidence. We also explain some concepts like Mendelian randomization and how that's been used to further bolster the case for APO-B as the superior metric for risk prediction. And we talk about where coronary artery calcium scoring comes in. This is obviously an important tool used by many physicians, and it's important to understand how it's useful and what its blind spots are. So without further delay, please enjoy my conversation with Dr. Allan Snider.
Hey, Allan, thanks so much for making time to sit down today. This is one of those discussions I've been meaning to have for over a decade, and I suspect much of what we speak about today will be reminiscent of things we've spoken about, usually in person over a meal, over the past decade. So welcome to the show, and sorry that we can't be doing this in person.

**Allan Sniderman** (4:48)
Thank you so much.

**Peter Attia** (4:49)
So I think listeners of the show will be pretty familiar with your name because certainly I've brought it up before, as have other people on the show, most notably probably Tom Dayspring.