u/kboom100

Technically you don’t have heart disease because the stenosis is less than 50%. But it’s a large enough narrowing that if I were you I’d want to go on a statin plus ezetimibe and if necessary a pcsK9 inhibitor and get my ldl below 55 and apoB below 60. That’s the point at which plaque accumulation is halted for almost everyone and you are likely to get some soft plaque regression.

I don’t think you need a Heartflow analysis because you already know it’s a good idea to aggressively lower your ldl / apoB.

PS- this is a good example of how stress tests are not good at finding atherosclerosis until it’s severe.

You’re welcome. Glad I can help.

Yeah, I think it’s the right mindset to feel hopeful or good about taking statins/lipid lowering medication. In your case lipid lowering therapy isn’t something you would be taking because you currently have a problem. The newer approach in cardiology is to take lipid lowering medication at a younger age so that you keep your arteries clear and avoid having a problem in the first place. That’s why you would be taking them.

As an analogy do you get upset that you have to brush & floss your teeth every day? I bet not because most people realize it’s a good idea to brush & floss to keep their teeth in good shape for life. I think of statins & ezetimibe similarly but for arteries.

In answer to your question there is a modest correlation between weight and ldl. But even if you lost the 40 pounds it’s highly unlikely you could get your ldl, or better ApoB, below 70. Losing weight, even small amount is still a good idea however and will probably reduce your ApoB/ldl some along with providing other health benefits like reducing insulin resistance and lowering blood pressure.

During your pregnancy did you develop preeclampsia, gestational diabetes, gestational hypertension or deliver prematurely? If so that raises your risk of heart disease even after the acute event has passed and would be an additional reason to keep your ldl /apoB below 70.

You aren’t cooked and you aren’t going to have a heart attack or stroke anytime soon.

However because you have a family history of early heart disease I think it would be smart to start a low dose statin or a low dose statin plus ezetimibe in addition to improving your diet and lifestyle. That’s especially given your implied desire to be aggressive about prevention and be around a long time for your children.

Heart disease risk is often multi factorial. Obviously smoking played a big part in your mother’s bypass surgery at 55. But for females a bypass at 55 is still early, even for someone that smokes. There’s a very good chance genetics significantly contributed to your mother’s bypass and that increases your risk. And you also mentioned genetic risk on your father’s side.

An ldl of 100 is ok for someone at average risk of cardiovascular disease. But those like you with a family history of early heart disease are not at average risk. A common recommendation from preventive cardiologists and lipidologists is for those with a family history of early heart disease to set an ldl target of under 70 or better go by apoB and get it under 70. You’ll need lipid lowering medication to reach that level.

According to guidelines everyone should check their lp(a) at least once in their lives. You especially should because of your family history. If your lp(a) high then that’s another reason to set an ldl and apoB target under 70. If your lp(a) is over about 180 nmol/L there are some preventive cardiologists who recommend getting ldl below 55, or better go by apoB and get it below 60.

However a normal lp(a) is not an all clear for genetic risk. Another response here said that a normal lp(a) is “strong reassurance” about genetics. That isn’t true. A normal lp(a) simply means you don’t have the genetic variants that raise lp(a). There are plenty of other genetic variants that raise someone’s risk of heart disease through mechanisms other than lp(a).

That same answer also said your absolute risk of a heart attack right now is very low and that you have decades to shape your heart risk. That’s only partially true and reflects an outdated view of how to optimally prevent cardiovascular events.

You do have a very low risk of a heart attack or stroke over the next 10 years simply because you are relatively young. However it’s not really the case that you have decades to get your ldl / apoB down to a good target. (And again, for you I think a good ldl target is not 100, it’s lower.).

It’s now known that the risk of a heart attack from lipids is related to cumulative exposure over time and not so much one’s lipid level at any particular point in time. The higher one’s ldl /apoB the relatively faster plaque accumulates in the arteries. If you wait a decade or more to get your LDL to a good target level you’ll be able to reduce your risk at that point. But you won’t be able to reduce it nearly as much as if you had gotten your LDL to a good target a decade earlier and prevented a lot of extra plaque from accumulating on your arteries in the first place. See an earlier post for a lot more information about this concept and links to evidence about it. (And be sure to swipe through the image to see the chart and table.) https://www.reddit.com/r/Cholesterol/s/fPj2342cpV.

A section of the latest European guidelines also acknowledges this concept too:
“Finally, this Task Force emphasizes that atherosclerosis is a chronic progressive disease that begins early in life and slowly progresses over time, and the cumulative exposure to higher LDL-C levels at younger ages is associated with a higher ASCVD risk later in life.34 Conversely, exposure to lower levels of atherogenic lipids at younger ages has the potential to reduce the lifetime risk of developing CVD35 and mitigate further progression of subclinical atherosclerosis.15 The discrepancy between our understanding of the biology of how atherosclerosis develops and the practical consequences of informing treatment decisions based on 10 year risk underscores the need to develop a new generation of risk- and benefit-estimating algorithms. These algorithms should: (i) accurately estimate the lifetime risk of having an acute CV event for all individuals regardless of age, and (ii) provide personalized guidance on the optimal timing and intensity of LDL-C lowering needed by each person to reduce their remaining lifetime risk of developing an atherosclerotic CV event.”
https://doi.org/10.1093/eurheartj/ehaf190

Here’s what the 2026 U.S. guidelines say about the approach to those with a family history of early heart disease but who are at low 10 year risk. (FYI the largest driver of 10 year risk is an age, so those under age 50 are overwhelmingly “low risk” just because of age). “Risk enhancers may also identify individuals with low estimated risk (<3%) by PREVENT-ASCVD equations who may be reasonable for consideration of LLT [eg, strong family history of premature CVD and/or very high Lp(a)] or may be included in the benefit-risk discussion for individuals at higher risk who have concerns about starting LLT.”
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001423#sec-8-2-3

That’s essentially leaving the decision on starting a statin up to the doctor and patient. And that makes it more important you see a doctor who is more knowledgeable about the importance of family history in determining risk and the benefits of getting ldl to a good target early in life.

So if I were you I would make an appointment with a preventive cardiologist or lipidologist. And if you want to be aggressive about prevention or already know you want to take lipid lowering medication I would explicitly say that during the appointment. The specialist database of the family heart foundation is a good place to find a good preventive cardiologist or lipidologist. https://familyheart.org/find-specialist

Then also get your other risk factors and lifestyle habits in line. The American Heart Association’s “Life’s Essential 8” is a good guide to follow for that. https://www.heart.org/en/healthy-living/healthy-lifestyle/lifes-essential-8

Yes, it makes sense to start lipid lowering therapy now. 10 year risk is mainly driven by someone’s age so anyone young is going to have a low 10 year risk almost by definition. But atherosclerosis starts from a young age and waiting to treat just allows more plaque to accumulate in your arteries. It’s like telling a 20 year old it’s fine to keep smoking for now because they are at low risk of having a heart attack before they are 30.

I’ve seen several posts from others in Canada running into the same difficulties getting access to lipid lowering therapy that you are. Yes go ahead and get the carotid CIMT because if it shows significant plaque it sounds as if your doctor will prescribe medication then. But if the scan comes back ok I’d still try to get an appointment with a cardiologist or lipidologist. They might be more willing to prescribe a statin than a GP. If you need to I’d pay out of pocket to see one.

You’re welcome! Yeah, I think that was the same graphic I saw.

That’s great that you got the opportunity to speak with a cardiologist. I would explicitly ask to go on a statin plus ezetimibe if I were you. Sometimes doctors will be willing to do something not in the guidelines if a patient explicitly asks for it. Mention that you want to get your ldl down from an early age because your lp(a) will have been high from birth and there’s solid evidence now that risk is related to cumulative exposure to ldl & lp(a) over time.
So the earlier you get your ldl down the lower your cumulative exposure to ldl will be and the lower your lifetime risk. See a previous post for more detail (and swipe through the graphic to see all the graphics I posted.) https://www.reddit.com/r/Cholesterol/s/BXYizohkLW

Also if you can pick which cardiologist you see and can choose one of the authors on that paper I think that would up the chances they’ll be willing to prescribe lipid lowering therapy if you ask.

Good luck! I hope you come back later and post an update, if you want.

Since you’ve used up the copay card annual maximum you could switch now to using the Goodrx price if you want. But only by using Goodrx’s codes and not submitting the claim to your insurance. So it wouldn’t count toward your deductible or out of pocket maximum.

Statins won’t directly improve your running performance. Significant atherosclerosis will decrease your performance however. Statins lower your risk of developing significant atherosclerosis and thus will help keep your performance from getting worse.

Only a small minority of people will get muscle related statin side effects. If you do get them you can reduce the statin dose or stop taking the statin and the side effects will go away. So I wouldn’t use fear of side effects as a reason not try statins.

No worries! That’s great extra information. Sounds like you are doing all the right things along with working toward quitting vaping. If you need help don’t be afraid to ask for it from your doctor. He or she can probably get it for you.

I also wouldn’t be afraid to go back to the glp-1 if you need to. It’s not a sign of failure- obesity is a chronic disease and the body often fights to stay at it’s highest set point. That’s one of the reasons the glp-1s are such a miracle drug. They can be used long term and keep people at a healthy weight. Not only that but they seem to reduce cardiovascular risk beyond just what one would expect from the weight loss.

Thanks for your updated reply with the extra information. That’s fantastic that you cleaned up your diet and dropped the weight.

I’d suggest also quitting vaping. That’s a remaining major risk factor and not worth it. And I’d try to get regular cardio and strength training into your routine. That along with your weight loss will also help keep insulin resistance low and improve blood pressure too. I also think it’s a good idea to purchase a home blood pressure monitor and check it a few times a year.

Do you know if you snore? If so I’d also ask your doc about checking for sleep apnea.

Well you’ve definitely got the history of early heart disease. Great job on aggressively getting your apoB down. Keep it up and your lifetime risk will stay low.

Really lucky that you discovered the atherosclerosis at a very young age! Out of curiosity what caused you to get a CTA?

Also curious if you have additional risk factors like a family history of early heart disease, history of smoking, high blood pressure, or prediabetes or diabetes?

Your lp(a) is high enough that it increases your risk of a heart attack or stroke by 3 1/2 times. When lp(a) is high a common recommendation from preventive cardiologists and lipidologists is to go on lipid lowering medication and get ldl below 70, or better, apoB below 70.

When lp(a) is above 200 nmol/L some recommend getting ldl below 55, or better apoB below 60. I think it’s a safe bet that more would suggest that with an lp(a) as high as yours. That’s what I would want if I were you.

I’d go to a preventive cardiologist or a lipidologist because they are usually more knowledgeable about what to do about high lp(a) and are usually more focused on prevention than average. A way to find a good one is with the resources of the Family Heart Foundation, a patient support and advocacy group for those with high Lp(a) or Familial Hypercholesterolemia. Their Care Navigators can give you personal help in finding a specialist, preparing for the appointment, finding support and learning more, etc. https://familyheart.org/care-navigation-center
Or you can search the Family Heart Foundation’s specialist database directly.
https://familyheart.org/find-specialist

I’d also ask about starting a low dose aspirin. There’s preliminary evidence it lowers risk in those with high lp(a). https://www.reddit.com/r/Cholesterol/s/7jqM1W2RYD

He has diabetes and a very high ldl cholesterol along with super high triglycerides. If he is drinking a lot of alcohol he needs to stop.

He needs to see his doctor who should prescribe statins and possibly additional lipid lowering medication and likely a diabetes medication like a glp-1, and/or an sglt2 inhibitor. In addition he should eat a healthy Mediterranean style diet, incorporate regular cardio and strength training, lose weight if he is significantly overweight (a glp-1 medication will help with this), keep his blood pressure under control and stop smoking and excessive alcohol consumption.

Also is it the same person that originally posted it who’s reposting or someone else? I don’t understand.

ApoB is always a more accurate indicator of risk than ldl, non-HDL, or triglycerides. And when you know apoB adding in those other values does not improve the accuracy of determining risk. In other words when you know apoB you should go by it and not those other values.

You were at lower risk in 2024.

Unless you’re eating a carnivore style diet or McDonald’s for practically every meal ldl doesn’t reach 190 unless someone has a genetic predisposition to high cholesterol. Add on a family history of heart disease and statins are the right move. You can temporarily fight genetics with lifestyle alone but it’s a losing battle over the long term.

Yeah, I’ve seen others from Canada talk about how difficult it is to get doctors there to prescribe statins unless ldl is very high or someone is late middle age. It’s frustrating.

Here’s a potential option if you want to be very proactive and are willing to spend money out of pocket. Canada has an official working group on high lp(a) composed of cardiology and lipidology experts. Earlier this year they released new guidance to Canadian clinicians on what to do about high lp(a). I haven’t read the full article yet because it’s behind a firewall. But I have seen a graphic from it and I think it still mostly sticks to the current Canadian guidelines on when to start statins and mostly just recommend intensifying ldl targets if lp(a) is high. https://doi.org/10.1016/j.cjca.2025.12.060

I suspect this because as an official working group of the Canadian Cardiovascular Society they can’t really go beyond the current guidelines. However if you really want to be proactive you could reach out to the university clinics of the authors / members of the working group and see if you can pay to see them as a private patient. If you explicitly ask them to prescribe a statin or a statin plus ezetimibe I think there’s a good chance they would. It’s going to take some money but I would think of it as an investment in your future health and honestly almost nothing is more important. You could Google the names of the author’s to find their university departments and then call them to find out how to get an appointment.

Dr. Gil Carvalho, an md/phd internist who I think is among the absolute best at reviewing the totality of the evidence on medical issues and clearly explaining it, did a video on Nattokinase a few months ago. I’d recommend watching it.

Here’s his intro to it: https://x.com/nutritionmades3/status/2075605681718092216?s=46:

“I went over all the human evidence on Nattokinase

The exciting parts and the out of control internet hype

Does it reduce plaque?

What about eating natto itself?

If you want to make an informed choice check out the full video below 🔽🔽🔽”

Here’s the video explainer itself:

https://youtu.be/qRLiXKRuUCI?

I think your mother is smart. An lp(a) of as high as yours more than doubles risk of heart disease. A common recommendation of preventive cardiologists and lipidologists when lp(a) is high is to start statins or statins plus ezetimibe and get ldl below 1.8. If lp(a) is above 200 nmol/L some even recommend getting ldl below 1.4.

I would get a second opinion from a preventive cardiologist or lipidologist. What country are you in?

Stress tests, including nuclear ones, actually do a poor job at picking up atherosclerosis. They’ll only detect it when blockage is 70-80% or higher and the heart isn’t getting enough blood. And plaques can rupture and cause heart attacks long before stenosis reaches that point.

Ct angiograms will show stenosis at a much earlier stage but insurance doesn’t usually pay for it unless someone has symptoms like angina. And even ct angiograms can miss a lot of soft plaque accumulation because it first builds up in the artery wall where the CTA can’t reliably pick it up.

I don’t agree that yours is more of a mental health issue than a physical one. I think your 30 year risk is actually much higher than 6% because of your family history of heart disease in their 70s. The PREVENT calculator doesn’t take that family history into account.

I think it would be a smart decision to take a low dose statin and you’ll find plenty of doctors that are on board with that and agree to prescribe it. In fact if I had to bet the vast majority of preventive cardiologists and lipidologists would take one themselves in your circumstance.

But since you don’t qualify for lipid lowering therapy under the guidelines with your current medical history you will need to be proactive. You could start with making an appointment with a preventive cardiologist or lipidologist on the specialist database of the Family Heart Foundation. They are much more likely to be oriented toward prevention. And then if I were you I would explicitly ask for a statin. Let them know you want to aggressive about prevention because of your family history. I’ve heard an interview with Dr. Dan Soffer, a past president of the National Lipid Association, where he said he will prescribe a statin for pretty much anyone who wants one. But he doesn’t usually proactively offer it if the guidelines don’t specify it. He said the patient asking for it gives him the freedom to prescribe despite the guidelines. And I think they’re are a lot of doctors who feel the same way.

If I were you I’d also ask to add ezetimibe a month after starting the low dose statin once you’ve determined you tolerate the statin well. Adding ezetimibe is pretty much all upside because it will lower your ldl an additional 20-30% when added to a statin and hardly ever has side effects. At least one very good preventive cardiologist, Dr. Pablo Corall, has said he basically automatically adds on ezetimibe whenever he prescribes a statin.

I’d also go ahead and ask for the carotid ultrasound with CIMT and CAC scan. I’d still want to be on the low dose statin and ezetimibe even if the imaging was clear. But depending on the results of the imaging it could make sense to set a more aggressive ldl / apoB target than you would otherwise.

I’d do all of this in addition to optimizing your diet and lifestyle.

- You should be extremely concerned about a CAC score of 48 at only 43 years old. To put it into perspective it’s at that 92nd percentile, which means it’s higher than 92% of other 43 year old males. It doesn’t mean you are likely to have a heart attack in the next couple of years but it does mean you are on a very high risk trajectory. You’ve got to change that trajectory and get your ldl way down.

The guidelines say that anyone with a CAC score above the 75th percentile should get their ldl below 70 mg/dL and at least a 50% drop from their baseline ldl.

Going by apoB is even better- you’d want it below 70 mg/dL at a minimum.
If I personally had a CAC score above the 90th percentile I would want my apoB below 60 (or below 55 if going by ldl). That’s the level at which plaque accumulation stops in pretty much everyone and where you are likely to get some soft plaque regression. To be clear, this lower target would be what I would want if it were me and isn’t from the guidelines.

At a minimum I would ask to add ezetimibe once you’ve been on the statin a month and confirmed you tolerate it well. Adding ezetimibe is pretty much all upside because it will lower your ldl an additional 20-30% when added to a statin and hardly ever has side effects. At least one very good preventive cardiologist, Dr. Pablo Corall, has said he basically automatically adds on ezetimibe whenever he prescribes a statin.

If the combination doesn’t reach your ldl /apoB target then you could up the statin dose or add a pcsK9 inhibitor.

- The medication, even on its own, will significantly lower your LDL & apoB. Switching to a plant based diet and keeping saturated fat below 13 grams per 2000 calories will bring your LDL down further although it’s likely the medication will still be doing most of the heavy lifting. So don’t feel like you have to become a vegan or that you can’t periodically go to the steakhouse.

- Lipid lowering medication along with good lifestyle and habits is how you deal with a genetic predisposition to heart disease.
Risk will go down in direct proportion to how much you lower your ApoB and for how long you keep it low.

I think your plan to change your diet, lose weight, and check your cholesterol again in a few months is very reasonable. I would check your apoB at the same time since it is a better measure of risk from standard lipids than ldl. If your ldl doesn’t go below 100, or better, your ApoB isn’t below 80 or you can’t sustain those levels long term, then yeah I think a statin or statin plus ezetimibe is a good idea. Cumulative exposure to ldl/ apoB drives plaque accumulation and lifetime risk. It’s a bad idea to let ldl and apoB remain elevated for years because you’ll slowly be building plaque in your arteries the whole time.

What units is your lp(a) in, nmol/L or mg/dL? Have your grandparents had cardiovascular events?

I think my skin type is just completely normal. I haven’t had any breakouts from using Light As Air and I’ve been using it 3 years now.