AMA #43: Understanding apoB, LDL-C, Lp(a), and insulin as risk factors for cardiovascular disease

**Peter Attia** (0:11)
Hey, everyone, welcome to a sneak peek, Ask Me Anything or AMA episode of the Drive podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created.
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So without further delay, here's today's sneak peek of the Ask Me Anything episode.
Welcome to Ask Me Anything episode number 43 I'm once again joined by Nick Stenson. In today's episode, we answer a lot of follow-up questions we've had on some recent podcast topics, specifically around insulin, hyperinsulinemia, ApoB, LP little a, and how they all relate to how a person should be thinking about their risk of atherosclerotic cardiovascular disease, which is just as a reminder, the number one leading killer in the US worldwide for men, for women.
So one of the things we try to do in this podcast is really get at the data around how much residual risk is conferred for ASCVD through metabolic dysfunction once you correct for ApoB. And there are some things that I think we have data that we can speak to, and we talk a lot about those things. So for example, we get into the mechanism by which hyperinsulinemia increases the risk of ASCVD. And of course, the question is, once ApoB is corrected for, does that risk still exist? Well, we attempt to tackle that. We also talk about what Mendelian randomization tells us about lifetime risk reduction of ASCVD in the context of low ApoB. So these are just a couple of examples of some of the topics that we get into at a pretty nuanced level in this podcast. If you're a subscriber and want to watch the full video of this podcast, you can find it on the show notes page. And if you're not a subscriber, you can watch a sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy AMA number 43

**Nick Stenson** (2:15)
Peter, welcome to another AMA. How are you doing?

**Peter Attia** (2:19)
I'm doing well, although looking at your T-shirt and realizing that you probably bought that at Coda, I'm a little less good because I'm realizing I somehow missed that shirt and didn't buy one myself.

**Nick Stenson** (2:31)
Yeah, it's a good looking shirt.
We didn't plan this, but we're both wearing the white, black and red today, just a little different fonts on the front. Do you want to tell people about your shirt?

**Peter Attia** (2:43)
I have a red hot chili peppers shirt. You have a Senna 1988 MP4-4 McLaren shirt, which I really like.

**Nick Stenson** (2:51)
Well, next year, we'll make sure to track one down for you.

**Peter Attia** (2:54)
I'll have to find it.

**Nick Stenson** (2:55)
All right, perfect. So Peter, for today's AMA, what we did is we just gathered a lot of questions that have come from past podcast content as relates to ASCVD. We've talked about this so much with AMA34. We covered what causes ASCVD. We've had podcast guests dive deeper into things that can mechanistically contribute to increase risk with LP LeLoi and Ben Wah, which is episode 210, Apo B with Alan Snyderman, which was episode 185, and then insulin with Gerard Schulman, which was episode 140 And that was also one we recently rebroadcast because we know we have a lot of new listeners who may not have heard that and the importance there. And so what we did is we combined a lot of these questions because there was a lot of people who are kind of wondering how they fit together, right? They know Apo B can increase risk. You know LP LeLoi can increase risk. Insulin, not good for ASCVD.
But the question is kind of, how can they collectively influence the risk of someone? You know, there's questions around if my Apo B is low, but my LP LeLoi is high. You know, if my insulin is good, but my LDL or Apo B is raised, how do I think about that? And so we compiled those questions and that's what we're hopefully gonna cover here today. So it's a little bit related to Formula 1, but not quite fully there.
But on the plus side, much like Formula 1, you do like talking about cardiovascular disease.
So at least it's an interest there. But anything you wanna add before we get started?

**Peter Attia** (4:32)
No, but just for the record, I do prefer talking about Formula 1 over Apo B, but I think Apo B is more important. So I'd probably spend more time talking about it, just to clarify.