Preventing cardiovascular disease: the latest in diagnostic imaging, blood pressure, metabolic health, and more | Ethan Weiss, M.D.

**Peter Attia** (0:11)
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Now, without further delay, here's today's episode.
My guest this week is Ethan Weiss. Ethan was a previous guest on episode number 52 way back in May of 2019 At the time, Ethan was a professor of cardiology at UCSF. Now, he still holds a position at UCSF where he focuses on preventative cardiology, but his main job is as an entrepreneur in residence at Third Rock Ventures where he is working on a project related to cardiometabolic disease, something that we touch on in this episode. He continues to have a small clinical practice in preventative cardiology, and a lot of our discussion really focuses on that. I wanted to have Ethan back on to pick things up where we left off. Over the past couple of years, Ethan and I always stay in touch and exchange emails. And at some point, those emails reach a critical mass where we decide, hey, probably time to bring this discussion to a bunch of listeners, namely you. In this episode, we focus a lot on ASCVD, of course, and we talk about the diagnostic tools available to understand risk. Because I realized that many listeners weren't necessarily listeners back three or four years ago, we go through a pretty good overview of the difference between a CAC and a CTA as diagnostic tools that give us enormous insight into someone's existing and future risk of ASCVD across various different risk factors. We speak about some of the newer versions of the CTAs, which really aren't so much about the CTAs, but are about some of the software overlays that are used to at least theoretically make the CTA more valuable.
Talk a little bit about how extreme endurance athletes may or may not be at higher risk for calcification. And we talk about potentially the role of statins in that. We then move on to a discussion about blood pressure. And in reality, I think this is such an important point that this will not be the final word on blood pressure.
But it is important to keep in mind that we do pay a lot of attention to lipids on this podcast. And lipids of course form part of the holy triad of risk for cardiovascular disease. But the other two things, smoking and blood pressure are obviously worth mentioning. Now smoking seems so obvious that it really warrants little attention on a podcast like this. Most of the people tuning into this are quite health conscious. They're generally not smoking. And we have done at least one podcast on smoking cessation. But I think in some ways, the discussion on blood pressure has been a little bit lacking. And that's why I really wanted to have that discussion today. So we talk about the importance of knowing your blood pressure, how to actually check your blood pressure, why high blood pressure is problematic beyond just the heart and spoiler alert, if you think it's bad for your heart, wait till you see what it does to your kidney. And then we talk about the different pharmaceutical agents out there and the trials that have taught us how these things work and when they should be instituted. Finally, we end the conversation looking at what we know and don't know about how metabolic health plays a role in ASCVD. Because if earlier I mentioned the holy triad of hyperbeta-lipoproteinemia, which is just a fancy word for elevated ApoB, smoking and blood pressure, there is still residual risk in people who have perfectly low and normal lipids, who don't smoke and have normal blood pressure. That doesn't mean your risk of ASCVD goes to zero. In fact, we know it does not.
And in fact, we talk about what that X factor is. What is it about metabolic ill health that drives residual risk in ASCVD? Anyway, this is a fascinating discussion, and I suspect it's only the thin end of the wedge into more exploration into blood pressure and some of the more nuanced cellular metabolic ill effects towards ASCVD. So without further delay, please enjoy my follow-up conversation with Ethan Weiss. All right, Ethan, thanks so much for making time to sit down again. This is round two, although I kind of don't remember when round one was. I think it was 2019, but it might have been 2018, right?