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Anna's Deep Dives

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You probably think you’re safe.

You eat reasonably well. You exercise. Maybe you even run marathons.

But here is a stat that kills the "fitness equals immunity" myth:

36% of marathon runners have significant coronary artery calcification.

And it starts earlier than you think. Autopsies show that 50% of children aged 2-15 already have fatty streaks—the precursors to plaque—in their arteries.

By the time you're 45, half the population has atherosclerosis. Most just don't know it yet because they rely on a standard physical.

And that physical? It uses a math equation from 1972 to guess your LDL cholesterol.

The result: 50% of people who suffer a heart attack have "optimal" LDL levels.

If that attack happens outside a hospital? Your survival rate drops to just 12%.

It’s not a plumbing problem. It’s an engineering failure.

For the last few weeks, we’ve been digging into the data to find out why fit, healthy people are dropping dead—and how to make sure you aren't one of them.

Here is the unvarnished truth about the new science of heart health.

The Illusion of Safety The "Widowmaker" artery supplies 50% of your heart's blood. A blockage here leaves zero margin for error. We explain why the standard lipid panel you get at your physical is failing to predict the crash. [Read Section 1: Why "Normal" is Not Enough]

The Genetic Time Bomb (That You Probably Have) There is a specific lipoprotein that 20% of the population carries. It’s genetic. No amount of kale or jogging will lower it. And standard statins don't touch it. If you haven't tested for this specifically, you are flying blind. [Read Section 2: The Genetic Silent Assassin]

Stop Counting Passengers, Start Counting Cars Your doctor measures the total weight of your cholesterol. That’s a mistake. The artery wall doesn't care about the weight; it cares about the number of particles crashing into it. We explain why "ApoB" is the only number on the scoreboard that really matters. [Read Section 3: The True Driver of Risk]

The "Zero Score" Fallacy You might have heard of a Calcium Score. It’s a good start. But a score of "zero" doesn't mean you're in the clear. It just means you don't have old scars. It misses the "soft plaque"—the unstable, invisible lesions that are actually prone to rupture. [Read Section 4: Seeing the Enemy]

The Fire Inside Arteries don't just get clogged like old drains. They get inflamed. We look at the root causes—endothelial failure and insulin resistance—that turn a stable vessel into a ticking clock. [Read Section 5: The Inflammatory Roots]

The Protocol Knowledge is useless without action. We compiled the "Advanced Panel." These are the specific blood tests (like Lp(a) and oxidized LDL) and the specific scans (like CCTA) you need to demand. Most doctors won't offer them unless you ask. [Read Section 6: The Advanced Protocol]

This isn’t about living forever. It’s about not dying stupidly.

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Table of Contents

^{(Click on any section to start reading it)}

Section 1: The Illusion of Safety – Why "Normal" is Not Enough

1.1 The "Widowmaker" Phenomenon: Anatomy of a Sudden Failure

• Defining the Widowmaker

• The Paradox of the "Fit" Executive

• The Mechanism of Rupture

1.2 The Obsolescence of the Standard Lipid Panel

• The Friedewald Equation

• The Limitations of Total Cholesterol

• The "Silent Gap"

1.3 The Difference Between Risk Factors and Actual Disease

• Lipids are the Smoke, Plaque is the Fire

• The Concept of "Arterial Age" vs. Chronological Age

• The Timeline of Atherosclerosis

1.4 The Economic and Personal ROI of Early Detection

• The Cost of Reactive vs. Proactive Cardiology

• The Impact of Cardiovascular Events on Executive Function

• Moving from "Sick Care" to True "Health Span"

Section 2: The Genetic Silent Assassin – Lipoprotein(a)

2.1 Lp(a) Explained: The Sticky Killer

• Structural Biology

• The "Triple Threat" Mechanism

• Evolutionary Origins

2.2 The Prevalence Reality: It’s Not Rare

• The Statistics

• The Heredity Factor

• Ethnicity and Variance

2.3 The Testing Gap: The Most Important Number You Don't Know

• Why Standard Statin Therapy Does Not Lower Lp(a)

• The One-Time Test

• Interpreting the Results

2.4 Managing the Unmanageable: Therapeutic Horizons

• Current Mitigation Strategies

• The Role of Apheresis

• The Future Pipeline

Section 3: The True Driver of Risk – Apolipoprotein B (ApoB)

3.1 The Cargo vs. The Boat: Reframing Cholesterol Transport

• The Crucial Distinction

• The Law of Diffusion

• The 1:1 Stoichiometry

3.2 The Discordance Problem: When Tests Disagree

• Metabolic Ward Studies

• The Danger of "Discordance"

• Small Dense LDL (sdLDL)

3.3 Optimal vs. Normal: Redefining Reference Ranges

• The Bell Curve Fallacy

• Physiological Lows

• Targeting the 5th Percentile

3.4 The Role of Triglycerides and Remnant Cholesterol

• The Triglyceride-Rich Lipoproteins

• The TG/HDL Ratio

• How Diet Drives ApoB

Section 4: Seeing the Enemy – Soft Plaque and Imaging Technology

4.1 The Calcium Score (CAC): A Good Start, But Not Enough

• What CAC Measures

• The "Zero Score" Fallacy

• When to Use CAC

4.2 The "Vulnerable Plaque": The Ticking Time Bomb

• Soft Plaque Characteristics

• The Mechanics of the Widowmaker

• From Inflammation to Occlusion

4.3 The Gold Standard: CCTA (Coronary Computed Tomography Angiography)

• Technological Leap

• Characterizing Plaque

• Quantifying Total Plaque Volume

4.4 Functional Testing vs. Anatomical Testing

• Why the "Stress Test" fails

• The Limitation of EKGs

• The Superiority of Anatomy

Section 5: The Inflammatory and Metabolic Roots

5.1 Inflammation: The Fire inside the Arteries

• The Response to Injury Model

• hs-CRP (High-sensitivity C-reactive Protein)

• Autoimmune Connections

5.2 Endothelial Dysfunction: Where It All Begins

• The Endothelium

• Nitric Oxide (NO)

• The "Glycocalyx"

5.3 Insulin Resistance: The Silent Accelerator

• Hyperinsulinemia

• The HbA1c Blind Spot

• Metabolic Syndrome

5.4 Oxidative Stress and Modified LDL

• Native LDL vs. Oxidized LDL

• The Role of Antioxidants

• Lp-PLA2

Section 6: The Advanced Protocol – Therapeutics and Lifestyle

6.1 The Pharmaceutical Toolkit: Beyond Just Statins

• Statins Revisited

• PCSK9 Inhibitors

• Bempedoic Acid and Ezetimibe

6.2 Nutritional Biochemistry: Feeding the Heart

• The Saturated Fat Debate

• Fiber and Sterols

• Omega-3 Fatty Acids (EPA/DHA)

6.3 Exercise as Medicine: Zone 2 and Hemodynamics

• Zone 2 Training

• Shear Stress

• Resistance Training

6.4 The "CEO" Action Plan: What to Ask Your Doctor

• The "Advanced Panel" Checklist

• The Imaging Directive

• Building the Team

Baked with love,

Anna Eisenberg ❤️