The Shocking Truth About Lp (a): NEW EVIDENCE
In a Nutshell
Lp(a) drugs that slash levels by 70-90% fail to reduce heart attacks because they ignore metabolic disease—the real driver of cardiovascular events. Standard lipid panels miss this by only measuring cholesterol cargo, not particle count, inflammation, or insulin resistance markers like triglyceride-to-HDL ratio and remnant cholesterol. Lifestyle changes targeting metabolic health (low glycemic carbs, intense exercise, sleep/stress management) outperform particle-focused drugs alone, while Lp(a) testing is still warranted once in a lifetime since levels are mostly genetic.
These notes were generated by AI and may contain inaccuracies.
Most primary care physicians order the same four-number lipid panel that has been standard for 45 years. Three of these four numbers are calculated rather than directly measured. Patients in their 50s and 60s often receive annual cholesterol panels where LDL is noted as slightly elevated, followed by a statin prescription, yet heart attacks still occur without warning. The standard panel fails to identify risk factors present on the chart for 10 years before cardiac events.
Cholesterol does not float freely in blood, as this would cause blockages and tissue damage. Instead, cholesterol rides inside particles, which are protein-based structures that carry cholesterol and triglycerides through the bloodstream. The body uses proteins to solve the problem of fat not mixing with water, forming what can be visualized as trucks carrying cholesterol cargo.
The LDL number represents the amount of cholesterol cargo within particles. Apo B represents a count of the particles themselves when measured in millimoles. Two individuals can have identical LDL levels, but one may transport the cholesterol in fewer large particles while another uses many smaller particles. Higher particle counts are associated with more cardiovascular problems, though particle count alone does not adequately reflect metabolic disease status.
Research indicates that among patients with metabolic disease in the United States, only 5% receive proper diagnosis and treatment. Out of 100 people with metabolic disease seeing their doctor, only five get the condition diagnosed, treated, and documented in their medical records. This represents a systemic failure in identifying metabolic disease, which drives most cardiovascular risk.
The triglyceride to HDL ratio, calculated from existing panel numbers, serves as the cheapest and most accessible marker of insulin resistance. The ratio is calculated by dividing triglycerides by HDL. A ratio under 2 is considered decent, while a ratio under 1 is the target. This calculation is not routinely performed by physicians despite being more important than other ratios commonly provided.
Remnant cholesterol is calculated by subtracting HDL from total cholesterol, then subtracting LDL from the result. For example, with total cholesterol of 180, HDL of 50, and LDL of 105, remnant cholesterol equals 25. The target is under 20, with optimal levels under 14. Remnant cholesterol represents particles not named on standard reports but carries significant inflammatory potential.
The liver releases particles loaded with fat that decrease in size as triglycerides are dropped along their path. Remnant particles return to the liver smaller and cholesterol-dense. High remnant numbers indicate metabolic dysfunction and represent a metabolic reading presented in cholesterol form. Remnant cholesterol is more inflammatory than standard LDL particles, and clearance depends on insulin sensitivity and metabolic health.
Fractionation separates and counts particles rather than estimating them through calculated values. Large HDL particles should number approximately 6,700. LDL pattern A consists of large, buoyant particles, while pattern B consists of small, dense particles. Small, dense particles demonstrate greater inflammatory potential than buoyant particles. When large HDL decreases and pattern shifts to B, this indicates insulin resistance affecting particles years before fasting glucose levels change.
Lp(a) testing should occur at least once in a lifetime due to its primarily genetic nature and minimal response to dietary changes. Levels above 300 nanograms per milliliter warrant consideration of treatment. Below this threshold, levels can typically be managed through lifestyle interventions. Most men and women have never had this test ordered.
Inflammation assessment requires a separate panel including myeloperoxidase, Lp-PLA2, CRP, and urine microalbumin to creatinine ratio. The standard panel cannot distinguish between individuals with identical Apo B levels but different metabolic and inflammatory profiles.
A phase 3 trial press release from Novartis regarding pelacarsen revealed that while the drug achieved 70-90% reduction in Lp(a) levels, it did not decrease cardiovascular events. The study failed to account for metabolic disease status among participants. Research indicates that only 10% of patients with metabolic disease receive proper evaluation in clinical settings, including research studies.
Two additional antisense drugs targeting Lp(a) remain under randomized clinical trial investigation. At least one may show a small signal of event reduction, though not conclusive evidence. These medications will likely remain expensive given current outcome data.
Lp(a) is considered primarily genetic, with the amount produced appearing to be the genetic component. While most individuals have some Lp(a), levels show minimal dietary responsiveness. Some patients have demonstrated 70% reduction with niacin treatment, though this is not universal.
Three major proteins form lipoprotein particles: Apo A1 forms HDL particles, Apo B forms LDL and related particles, and Apo(a) or Lp(a) forms the Lp(a) particle. Apo(a) is structurally similar to Apo B and contains kringle repeats that form hook-like structures. These proteins have lipophilic sides that attach to fats and cholesterol, and hydrophilic sides that interact with the water-based bloodstream.
The first three particles shown in fractionation graphics represent remnant cholesterol particles, which are triglyceride-rich and highly inflammatory. While some debate exists regarding whether triglycerides themselves cause inflammation, remnant particles demonstrate consistent inflammatory properties. Individuals with low triglycerides typically show lower cardiovascular event risk.
When Lp(a) and LDL are lowered without corresponding event reduction, residual risk factors must be considered. Mainstream medicine typically identifies diabetes and other causes as residual risk, but metabolic disease represents the primary rather than residual driver of heart attacks and strokes. Lifestyle interventions addressing metabolic disease should accompany any particle-focused interventions.
Recent evidence indicates that reducing saturated fat does not lower Lp(a) levels. Some small studies suggest high saturated fat might actually reduce Lp(a), though this requires further investigation. Niacin remains the primary intervention discussed for elevated Lp(a), with modest effects noted from ginkgo and carnitine in limited studies.
PCSK9 inhibitors lower Lp(a) more than any other current drugs, though the clinical impact on preventing heart attacks and strokes remains unclear without lifestyle optimization.
Lp(a) has been presented as a major risk factor for years, similar to LDL. However, the fundamental position is that undiagnosed metabolic disease represents the primary driver of cardiovascular problems, not LDL or Lp(a) particles themselves. LDL and Lp(a) may play contributory roles but are not considered the root cause of cardiovascular disease.
For patients dissatisfied with standard LDL-focused care involving statins, a contact number (859-721-1414) and QR code are provided for accessing alternative preventive medicine services. Dr. Brewer is noted as the only preventive medicine physician licensed in all 50 states, with additional health coaching services available to address lifestyle factors.
Lifestyle modification is emphasized as the primary driver for metabolic health, with supplements and medications considered secondary interventions. The approach prioritizes addressing metabolic disease over targeting Lp(a) in isolation.
Regarding a newly approved Lp(a)-lowering drug with initial studies showing no impact on cardiovascular outcomes, the recommendation framework involves patient education rather than prescriptive guidance. The physician's role is to present facts and support patient decision-making while maintaining lifestyle as the central focus.
Lp(a) testing uses two measurement systems: milligrams per deciliter (mg/dL) with a typical threshold of 50, and nanomoles per liter (nmol/L) with ranges of 125-150 corresponding to the mg/dL values. Quest and LabCorp increasingly report in nanomoles. Values under 200 nmol/L, and certainly under 300 nmol/L, do not warrant immediate pharmaceutical intervention.
For patients with elevated Lp(a) considering the new drug, the approach involves:
- Prioritizing lifestyle intervention, particularly addressing BMI, body fat percentage, and visceral fat
- Considering a trial period with monitoring of inflammatory markers, plaque morphology, and other biomarkers
- Evaluating cost-effectiveness, noting the drug may cost thousands of dollars annually without insurance coverage
- Insurance companies likely to restrict coverage to severe Lp(a) cases only
Glucose Manager is a proprietary blend developed to address insulin resistance and metabolic disease, containing berberine as the primary ingredient, fenugreek seed extract for enhanced absorption, chromium, vanadium, L-carnitine, and alpha lipoic acid as the main antioxidant. The supplement is available through Dr. Brewer's quality supplement store.
While acknowledging the need for additional research on Lp(a), ApoB, and LDL, the emphasis remains on independent research rather than industry-funded studies. Novartis's recent publication showing their Lp(a)-lowering drug did not reduce cardiovascular events is cited as an example of transparent negative results despite significant financial implications for the company.
Creatine, collagen, and small amounts of MCT oil or fish oil (under one teaspoon) during fasting periods are not considered problematic. A true fast involves dramatic caloric reduction and decreased sugar intake; minimal supplement intake does not significantly impact these primary fasting mechanisms.
For a 46-year-old beginning high-intensity interval training, maximum heart rate calculation uses the formula 220 minus age, with 80% of maximum considered optimal for zone training. Zone 5 (maximum effort) does not provide additional benefits over zone 4 and carries higher injury risk. Safety considerations include gradual conditioning progression, with heart rhythm issues and injuries representing greater risks than heart attacks during exercise. Beta blocker use affects achievable heart rates.
Patients who have received stents and are physically fit can often resume intense exercise, with cardiac rehabilitation recommended but not necessarily limiting for those who understand their exercise boundaries.
Patients undergoing major surgery (including laparoscopic robotic hernia repair) demonstrate better outcomes when metabolically healthy, with controlled blood pressure and fitness levels. Active engagement in healthcare decisions correlates with improved surgical results.
Extra virgin olive oil from single-origin sources in dark bottles is preferred, with California certification and similar standards helping identify quality products. Research benefits have been specifically demonstrated with extra virgin rather than regular olive oil.
Glucose Manager can be safely combined with MK4 (45mg) and low-dose aspirin, with no known contraindications. Supplement regimens are individualized based on patient needs, side effect profiles, and necessity assessments.
Novartis's publication of negative results for their Lp(a)-lowering drug demonstrates significant financial losses for the company, estimated in millions to billions of dollars. This transparency challenges assumptions about industry research manipulation, while acknowledging that all research tends to emphasize positive findings and minimize negative results.
Multiple studies have demonstrated that certain medications successfully lowered Lp(a) levels and improved bioindicators, but these interventions did not reduce major adverse cardiovascular events (MACE).
Calvin shared his personal health journey on the channel's house call series playlist, demonstrating a successful case study that viewers can reference. This story may be linked at the end of the show for those interested.
The analogy compares having the best fire retardant to addressing inflammation in arteries: if inflammation is already present, a fire retardant approach is insufficient - what is needed is a fire extinguisher approach instead.
The glucose manager supplement contains the following ingredients: vanadium, chromium, L-carnitine, alpha lipoic acid, berberine, and fenugreek seed extract.
First: Test, don't guess - confirm actual levels before taking action.
Second: Reduce glycemic carbohydrates, which has population-level relevance for overall cardiovascular risk.
Third: Add exercise with intensity to the routine.
Fourth: Remove roadblocks by ensuring good sleep quality, managing stress effectively, and maintaining a sense of purpose in life that transcends immediate feelings or cravings.
Medications and Supplements: Consider both options as appropriate - there are specific times and places where medications provide value.
Ongoing Process: Health management is not a one-time intervention but requires returning to fundamentals and building incrementally. The principle acknowledges that growing old presents increasing challenges, but consistent small improvements in effectiveness become manageable with practice.
"Growing old is not for sissies, but it's a lot better with healthy arteries."
The program closes with an invitation to join the regular Saturday show at 11:00 a.m. Eastern time.
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