Lp(a) Caused Bob Harper's heart attack, It's PrimeTime Now

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ABOUT THIS VIDEO:
Bob Harper, well known fitness guru, had a near-fatal heart attack in his early 50s in the winter/spring of 2017. He announced that it was due to a genetic problem. Then he later announced it was Lp(a).
Lp(a) is a genetic variation of the protein in LDL, which is formed by the body to keep fats and oils from forming large "fat emboli". Fat emboli can be seen in auto accidents or other serious trauma situations which result in bone marrow fat release into the blood.
There has been debate about Lp(a) for years. A September 2014 article in JACC (Jl of the American College of Cardiology) was titled, Lp(a): Is it ready for Prime Time? Bob Harper's announcement put it in prime time, ready or not.
Lp(a) has Kringle repeats hanging off the particle. This is believed by many to cause the increased atherogenesis, thrombogenesis, and inflammation associated with Lp(a).
There is excellent science showing that Niacin lowers Lp(a). So do other things, like estrogen, testosterone and anabolic steroids, PCSK9 medications, and apheresis.
So why don't most docs screen for it? In the US, the standards committees are not there yet. There's struggling with what's not known yet.
All of us agree, however, that known additional causes of heart attack and stroke should be even more aggressively managed in patients with elevated Lp(a).
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ABOUT DR. BREWER
Dr. Brewer started as an Emergency Doctor. After seeing too many preventable heart attacks, he went to Johns Hopkins to learn Preventive Medicine. While there, he went on the run the post-graduate training program (residency) in Preventive Medicine. From there, he made a career of practicing and managing preventive medicine and primary care clinics. His later role in this area was Chief Medical Officer for Premise, which has close to 1,000 primary care/prevention clinics. He was also the Chief Medical Officer for MDLIVE, the second largest telemedicine company. More recently, he founded PrevMed, a heart attack, and stroke prevention clinic.
At PrevMed, we focus on heart attack, stroke, and cognitive decline. We serve patients who have already experienced an event as well as those who have not developed a diagnosis or event. Dr. Brewer provides services via telemedicine or in person if you're in the Lexington, KY area. We find a lot of undiagnosed prediabetes or insulin resistance. Treating unrecognized risk factors like prediabetes allows reduction of risk and prevention of disease.
If you are interested in becoming a patient, please visit our website: prevmedhealth.com.
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[@a.g.hustlegarland4197]

Does it matter if the niacin is flush or no flush

[@PrevMedHealth]

Yes. Most No-flush niacin use chemicals which can degrade the positive impact of the niacin. Wax matrix extended release is the way to go.

[@frankenz66]

Reading large parts of Dr. Rath's book "Why Animals Don't get heart attacks, but people do'' he states that LPa is the substitute for vitamin C our body uses since we no longer make our own vitamin C. Doing it's job of repairing our circulatory system, but because of it's stickiness is a severe flaw. He also says 2-4 grams daily of nicotinic acid lowers LPa by a third. That is a lot of B-3!

[@PrevMedHealth]

Both of those are accurate in my experience.

[@frankenz66]

@@PrevMedHealth I am concerned that ascorbic acid being only the "sticky adhesive packet" ingredient that the vitamin C molecule is contained therein, is dangerous to take alone. Because vitamin C molecules you may have picked up in your diet may bond to that ascorbic acid adhesive and be passed on out of the body at a higher rate of frequency. I have read that ascorbic acid taken in high doses, alone, is a good way to be even more lacking of the whole vitamin C nutrient. Is that plausible? I won't take it alone. It is sold widely as you know, but whole C is difficult to find, and expensive when you do. I consume lemons and limes almost daily.

[@abc_cba]

@@frankenz66 Can you put forward the evidence on ascorbic acid reducing vitamin C , please ? If that's the case you should search out for camu camu berry or acerola cherry or Amla which are natural substitutes for vitamin C . I'd not suggest you their powders as vitamin C is very unstable and all powders are dried making them void of vitamin C , Google about this Australian berry which has the highest Vitamin C content for any food on the planet. Opt for fruits instead of extracts is what I'd suggest you.

[@thanasis_k]

@Ford Brewer MD MPH hello doctor. thank you for all your help. does vitamin b3 raises blood glucose?

[@dmmcmah1]

@@thanasis_k he stated in a comment above that it can in some people but it usually resolves in six months

[@naturenut8790]

Excellent info.

[@salmansiddiqui]

Dr. Brewer, thank you for all of your educational videos. I noticed that you mentioned that testosterone and other anabolic steriods may reduce Lp(a) between 30-70%. From your experience, do patients with heart disease have low testosterone? I had a myocardial infarction in 2015, at age 36, and have a low testosterone too (200-250 range). I thought it was due to lipitor 40mg I am taking or metropolol 25 mg , and didn't want to take Testosterone replacement therapy as it kills the fertility, so wanted to see if you can shed some light on this issue of low testosterone (which I learned only after the heart episode). Thank you!

[@salmansiddiqui]

Thank you, John, for sharing your experience and advice. My Lp(a) history has been 120 nmol/L (2015), 126 nmol/L, and 112 nmol/L (2017). I have not used niacin as yet. I can check with my cardiologist, but it doesn't seem he would want to reduce the dose of the statin, they did reduce it from 80mg to 40 mg after the first 6 months after my heart attack in 2015 as my LDL were at 52, now they are around 113, and they like it to be around 70! But I will check with him. Thanks again for your time and advice.

[@incognitotorpedo42]

PCSK9 inhibitors and antisense drugs seem like good options for lp(a), except for their absurd cost (and unavailability, in the case of antisense). Niacin lowers lp(a) and is affordable, but has a problematic effect on serum glucose, as well as bothersome flushing reactions. Carnitine, on the other hand, has essentially no downside. It is very inexpensive, either as L-Carnitine or Acetyl L-Carnitine, available from supplement vendors. It has no side effects that I'm aware of. I've been using 500 mg acetyl L-carnitine twice a day for years. It had a noticeable effect on my lp(a) level; around a 15-20% improvement. Because PCSK9 inhibitors are mAbs, they are unlikely to ever be inexpensive, even after coming off patent, and they require injection. Antisense drugs are still in the pipeline, but at least have some promise of affordability, eventually.

[@green15838]

There is always a cost effective way.

[@timothybucky7170]

Lp(a) levels generally parallel the rates of heart disease in many populations, with a few exceptions. Eskimos, native Americans, Hispanics, Chinese, and French, populations with lower rates of heart disease, have lower levels of Lp(a) men in the highest quintile had a threefold increase in the risk of stroke and death from vascular causes, and nearly twice the risk of death from all causes. The risks persisted after adjustment for standard risk factors.197 Other studies have shown a striking absence of high Lp(a) levels in healthy octogenarians, possibly due to early death in those with high levels.200

[@PrevMedHealth]

Thanks

[@jillmorton3096]

Vegan, don't drink, don't smoke, I dont eat any oils or eggs and I exercise daily. I had a major heart attack a month ago while running with my son's dog. I was life flighted to the hospital from a hospital that didn't excel with the heart. I had 2 stents. I had 100% blockage on right side. My emotions are up and down as I had the blood test that showed that I have elevated lipoprotein a. It was 166 about 5 weeks ago. Any input to help would be appreciated . Im going through cardiac rehab. Im on pills I cant even pronounce. I dont want to be on meds my whole life. Im 54🙄

[@beckyg8028]

How are you doing now? Your Lpa is not that high. Keto is a better diet as it reduces inflammation & insulin. Also the Linus Pauling protocol is very effective for reducing Lpa. It's Vit C ascorbic Acid powder, lysine powder & proline. It's explained in "Practicing Medicine Without A License " book.😊

[@timothybucky7170]

Physician’s Health Study, a high Lp(a) (highest quintile) was associated with a 4-fold risk of CAD which increased to 12-fold in those who had LDL-C >160 mg/dL.3 In patients with high LDL-C levels, Lp(a) is a major factor in determining atherosclerotic disease, severity, progression, and event rate.149 and 150 0 This risk increased to 122-fold when high Lp(a) and high TC/HDL-C ratios were accompanied by ≥2 nonlipid risk factors.10 The combination of Lp(a) plus homocysteine induced more tissue factor activity than either agent alone.163 The risk of CAD risk is increased 12- to 30-fold with concomitant elevations in Lp(a) and homocysteine.10 and 164 This multiplicative effect may be mediated by the 20-fold increase in Lp(a)’s affinity for plasmin-modified fibrin induced by homocysteine.10 and 165 Other studies have shown synergistic adverse effects of Lp(a) with fibrinogen and the apolipoprotein epsilon 4 allele.166 and 167 The multiplicative effects on CAD risk of excess Lp(a) with other risk factors suggest a need for a change from the conventional practice of measuring Lp(a) only in those individuals who have none or few other risk factors.11, 156, 159, 162, 168 and

[@PrevMedHealth]

Thanks. The standard practice I have seen is not to measure in Lp(a) in anyone. It’s based on the incorrect assumption that nothing can be done. I measure it, and follow it, on al my patients.

[@perlaespejo3305]

Now i am convinced not to take may statins, rather i folw all your videos to prevent having inflammatory diseses.. thank you Doctor Brewer..

[@timothybucky7170]

It has long been noted that niacin therapy can have adverse effects on glycemic control in patients with type 2 diabetes or metabolic syndromeIn the Arterial Disease Multiple Intervention Trial (ADMIT), niacin had relatively minimal effect on glycemic control in patients with well-controlled type 2 diabetes (57). In the Assessment of Diabetes Control and Evaluation of the Efficacy of Niaspan Trial (ADVENT), moderate-dose niacin was given to patients who had type 2 diabetes but no clinical cardiovascular disease (58). There was a modest increase in hemoglobin A1C values from 7.2% to 7.5% in the niacin-treated subjects. Data in nondiabetics with impaired fasting glucose are limited, but some of these patients may experience an increase in fasting glucose with niacin therapy that approaches the mild diabetes range. Thus, the decision to add niacin to a statin in patients with type 2 diabetes or impaired fasting glucose must balance the lipid benefits against the possibility of slightly worsened glycemic control.

[@PrevMedHealth]

Thanks. Although there is some truth to that, niacin’s glycemic impact resolves in 6 months. When statins impact it, they do not resolve.

[@wcbibb]

Very informative video!

[@PrevMedHealth]

Thanks!

[@PreciousKing]

@@PrevMedHealth How much Niacin to take to help lower Lp(a) and this video was done two years ago, is there more data and information on treatment for this?

[@oibal60]

I was running a 10K in Central Park, NY, several years ago and had just finished - when lo and behold - at the bananas n Gatorade table - I spotted Bob! He was still quite thin & healthy looking. Yup, I got his autograph.

[@jameswilliamson7419]

Hi, I very much appreciate your videos Dr Brewer. I have learned so much. Your comments about aforesis triggered a question in my mind. Instead of this long process of sorting the blood (taking out the proteins and reinjecting the blood cells) how about donating blood on a regular basis. Will that have the same effect on LPa? I am concerned since my levels have been as high as 246. James Williamson

[@robertdaymouse3784]

FWIW, I have gotten a 10% reduction in Lp(a) with Ezetimbe, and an additional 20% reduction with L-Carnitine. Niacin makes me flush horribly even at 500mg. Tom Dayspring no longer recommends Niacin for Lp(a), so I am inclined to not try the wax matrix extended release you mentioned. Curious if you are still recommending Niacin 5 years hence.

[@PrevMedHealth]

Thanks for sharing. I’m less concerned about Lp(a) in the vast majority of cases.

[@Winstonsmom]

How useful is niacin if your lp little a is 1.25 g per litre? Even if it cuts it in half it’s still double what it should be. I live somewhere that doesn’t offer apheresis either. Also, there seems to be 2 schools of thought on diet strategies. Vegan at one extreme; keto at the other. How is a person to know what to do?

[@beckyg8028]

Keto is best as it reduces inflammation.

[@Werebat]

"Does lowering Lp(a) improve morbidity/mortality?" Here is my fear - that lowering Lp(a) would have a much more profound impact on morbidity/mortality IF DONE BEFORE PATIENT CAC>0. In other words, lowering Lp(a) in high Lp(a) children and young people may help delay the "crack in the windshield" that occurs when CAC>0, where that crack just grows and grows after it appears. I fear this to be the case because it will be generations before we are able to figure it out - who will be willing to test the new antisense drugs on children?

[@drott150]

_"who will be willing to test the new antisense drugs on children?"_ You certainly have the answer to that question now!

[@MrLeewsee]

what about elevated homocysteine levels? did I miss the video addressing this risk?

[@edwardchoi8299]

Can Niacin cause Macular? I took 1.5g of Niacin to reduce my cholesterol level, and about a month of talking this, I felt nausea, losing appetite and tired in the afternoon. I thought this may be due to liver issue with Niacin so I stop taking it for a couple of days and these symptoms disappeared. My blood pressure has come down and cholesterol level reduced. Is it safe to take Niacin at lower dose (maybe 0.5g or so). If my liver reacted to niacin, can this be changed with lower dose?

[@kathleenmorris811]

I was taking 1500mg but it caused my blood pressure to drop too low 89/47 and my feet and legs blew up with fluid. Any suggestions? Thank you Dr Ford!

[@PrevMedHealth]

Thanks.

[@michaelsmith1262]

Dr. Brewer, I hope you can answer my question. I recently had a lipid test done and unfortunately, it was not good. While I don't have elevated LP-a, I do have pattern B LDL, with high small dense particles, and the levels of the other sized particles are bad as well. My Triglycerides are good and my T/HDL ratio is good. My C-RP was good, insulin level good, A1C good. Total cholesterol and LDL are high though. I have been on Keto for a year, so I think it's possible these numbers could have been ever worse before. Am I correct that there are no medications to improve these numbers? Apparently, I was unlucky to be born with this. My father is 76 with no heart events, and my mother died at 76, not heart related. Dr wants me on statins, but they don't affect particle size.

[@PrevMedHealth]

Thanks for sharing. Statins impact LDL (and Total cholesterol). I agree re: other impacts. To me, the bigger question is whether you have plaque. In most cases, statins don’t stop the process of plaque deposition, but the right ones (usually not Lipitor) can help slow down inflammation. Age is important. IR status is critical.

[@michaelsmith1262]

Thanks, I hope to get a CIMT or CAC soon. Is there any data that lowering total and LDL has any beneficial effect on this type of metabolic situation? That being Pattern B.

[@michaelsmith1262]

@John Lorscheider I've been low carb for a year.

[@tomd790]

If you still have this issue after being on a keto diet for quite a while and you are consuming a lot of saturated fat in your diet, I have heard a potential reason for the paradox of increased TC and LDL-C (and LDL-P by the way). The proposed solution, which seems to work at least for some people, was to switch from consuming primarily saturated fats to olive oil. The numbers of people who have this issue are relatively few, and so the results are therefore anecdotal. I am not aware of a study to cite. The thought behind the paradox was that these people make significantly more cholesterol in response to the large amount of saturated fat rather than issues with increased cholesterol re-absorption. Good luck.

[@erharddinges8855]

So we will end up in polypragmasie and fighting the negative side effects with additional medications?

[@PrevMedHealth]

Polypharmacy is dangerous and way too common.

[@incognitotorpedo42]

Watching a video about a variety of treatment options in no way requires one to engage in polypharmacy. It's akin to reading a book about treatment options. Dr. Ford was not promoting polypharmacy.

[@robrae14]

All of your videos are outstanding. I have been on a vegan diet for 8 years. My blood labs a month ago were still higher than they should be given my lifestyle. Height and weight normal, exercise every day. Eat little to no bad fats...even make my own oil free salad dressing. So why is my LDL still at 113? Total C at 199, HDL at 68.2 and Triglycerides at 88? I got my Lp(a) tested a week ago and still waiting for results. Whatever those results are, should I just start on niacin alone and see if I can lower my numbers? (Before these results I shared above my numbers were LDL 129, Total C 227, HDL 87 and Triglycerides 54) I took an OTC plant sterol. It lowered my LDL a tad but lowered my good HDL and raised my triglycerides!!! Should I stop taking it? Thanks for your guidance, Robin

[@robrae14]

Hi John, I see you really educated on this topic. I just got my results for my Lp(a) and it's 204! I'm only 55 and have never taken any medications and I'm otherwise so healthy! What can I do to lower this or is it "normal" for me?

[@robrae14]

Gosh John you are really helpful and I really appreciate your time. I was stunned. I'm normal height and weight and always have been. I've been vegan for 8 plus years and don't eat an over abundance of carbs. My BP is normal and I never even get a cold. I have just started the slow release niacin. I'm adding a Vit C and K supplement along with a couple others I have read about on this website. Can I get both those tests you mention from the Cleveland Heart Lab? Many thanks!

[@PrevMedHealth]

John’s a great model for patient self-advocacy.

[@robrae14]

John Lorscheider Thank you, I will get these tests done. But you say not much of what I am taking will be helpful? I’m now stressed and anxious and can’t live this way. Do people with my high number just hope we don’t have a life ending event? My parents both lived until 79. My dad had dementia with Lewy Body and his whole body shut down uniformly. My mom (Who had high BP since her twenties and took meds for it) died by choice at home after being hospitalized for a UTI that caused kidney infection and ultimately failure. She didn’t want to live anymore - missed my dad too much - this all happened last year. :( Anyway should I see a cardiologist or an internist in my area?)

[@robrae14]

Ford Brewer Good morning and thank you for providing such outstanding education for us! Can I be your patient here from California?

[@kenrach9875]

Dr. Brewer did you watch the videos I posted

[@kenrach9875]

I've been taking 1000 mg of slo-niacin

[@IlIKRATOSIlI]

No one ever mentions what Bob's level actually was.

[@PrevMedHealth]

True. I have wondered that myself.