1/ ☠️ Thread ☠️
Looking at Heart Disease vs All Cause Mortality
Let's start with a poll. Would you prefer: 1. Being less likely to die of heart disease 2. Being more likely to die of something that isn’t heart disease
2/ The “how” you die is important, but probably not as important to you as “when” you die.
But could we just look at the "how" and "when" of one kind of mortality and know whether it will truly extend lifespan?
3/ If I hold an experiment and my intervention group died 50% less by heart disease than my control.
Can I conclude this intervention group must necessarily live longer than the control group on average – particularly given heart disease is our number one killer?
4/ It cannot. We don't have enough information when looking at only one kind of mortality. What we *want* to infer is that heart disease went down and all other risk factors remained the same.
That's very intuitive. That's how we think of it like the poll answer in (1) above.
5/ What if something makes you more vulnerable to another mortal illness that isn't heart disease?
Technically speaking, that will reduce your risk of dying of heart disease.
For a hyperbolic example, consuming cyanide would reduce your risk of dying by heart disease 100%
6/ Which brings us to genetically high and low LDL cholesterol (LDL-C). There is a known association between LDL-C and heart disease, and this includes genetics.
So an obvious question comes to mind, do those with naturally lower LDL-C live longer?
7/ That was actually the very first question I wanted to find out at the very beginning of my research in Nov' 2015.
It seemed relatively simple -- if people with genetically low LDL-C were blessed with longer lifespans, then the case was made, full stop.
8/ There are actually many different genetic ways one gets to low/no LDL-C/-P with technical names like abetalipoproteinemia, familial hypobetalipoproteinemia, and PCSK9 LOF.
Do they live longer?
They don't.
Why?
9/ This brings us back to the beginning. Three scenarios:
1. Less heart disease risk, all else the same 2. Less heart disease risk, one or more risk factors worsen (trade off) 3. Heart disease same, one or more risk factors worsen (net loss)
10/ In all three of the above scenarios we get less death by heart disease and more death by something else.
There's just one way to help understand the trade off -- you have to track mortality by non-heart disease as well.
You need All Cause Mortality (ACM)
11/ A couple weeks ago @JakeKushnerMD brought this up regarding the podcast @ethanjweiss had with @skathire. (I only just now listened to the podcast today) Here's Jake's tweet:
@JakeKushnerMD@ethanjweiss@skathire@mvholmes@mrbase2 13/ To be sure, I was hoping for LDL-C vs simply "Age at Death". I found later that this endpoint actually does exist and ran the data for myself. Finally seeing
Genetically higher LDL-C
vs
"Age at Death"
...
@JakeKushnerMD@ethanjweiss@skathire@mvholmes@mrbase2 14/ But I'm not going to link the graphic yet. Yes, I'll hint that it doesn't look good for pro-lipid lowerers, but I'm going to take more time to better understand from their position why they'd say it is.
That's why I wanted to understand @mvholmes position and a few others...
To @JakeKushnerMD's point, we can only know when good scientists like @skathire can take these massive population analyses beyond heart disease and apply them to all cause mortality as well.
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First, let me say that data on this has been a bit limited. But *IF* we do ultimately confirm there are more ApoB-48 (B48) than ApoB-100 (B100) in ASCVD plaque, it would be a very big deal.
Let's unpack...
2/ First, thanks to @TuckerGoodrich for pinging me on these pubs and pressing the discussion.
But also credit to @CaloriesProper on tweeting this a couple years ago (I missed it then)
To understand why this would be so important if true, some review...
3/ B48 and B100s are the major proteins on chylomicrons (CMs) and VLDLs, respectively.
CMs mostly carry lipids from the small intestine to the bloodstream (lipids consumed), VLDL mostly carry lipids from storage; predominantly from adipose stores.
#Me: Why would triglyceride rich LDL particles be more atherogenic than triglyceride poor LDL particles?
#ChatGPT: Triglyceride-rich LDL (low-density lipoprotein) particles are more atherogenic (i.e., more likely to contribute to the… twitter.com/i/web/status/1…
2/
#Me: Couldn’t it also be possible that triglyceride rich LDL are ultimately the result of metabolic dysfunction and that better explains its association with atherosclerosis?
#Me: Is it possible that almost the entire amount of atherogenesis associated with high triglyceride rich LDL is due to dysfunctional lipid metabolism and the diseases that result in these profiles rather than the LDL particles themselves?
1/🧵 I'm definitely a fan of both @DominicDAgosti2 and @DrRagnar (obviously), so I was excited to see them chatting about #lipids, #LMHRs, and Dom's consideration of increasing carbs to lower his #ApoB
3/ When chatting with Dom in SD last year for dinner, he mentioned focusing less on maintaining such a sizable muscle mass as he typically does, and I predicted he'd likely see his LDL/ApoB as considerably higher with this change if still #keto. This podcast appears to confirm...
But I also know many people in my own family who have struggled their whole lives to lose weight and assume if they don't have this near instant drop to their goal weight like <fill in the blank success story> then they are doing it all wrong...
... I can't tell you how many times I point out truly new, record-setting successes with people I know personally -- but it's their own record, their own health journey.
But they often can't see it because they hear they "won't be hungry anymore on <fill in blank diet>"...