Tools for Avoiding Heart Attack & Heart Disease | Dr. Peter Attia & Dr. Andrew Huberman
00:00:00.000 | When I was in medical school, we had a, and I think I even write about this in the book,
00:00:07.400 | we had a pathology lecture where the professor stands up there and he says, "What is the
00:00:14.820 | most common presentation of a heart attack?"
00:00:18.760 | And you know, us keener first-year med students, hands shoot straight up.
00:00:22.680 | Chest pain.
00:00:23.680 | No, that's not the most common.
00:00:25.560 | Oh, shoulder pain.
00:00:27.280 | Arm radiating down the left arm.
00:00:28.760 | No.
00:00:29.760 | Shortness of breath.
00:00:30.760 | No, no, no.
00:00:31.760 | We rattled this off for a few minutes, and he goes, "Death."
00:00:36.080 | The single most common presentation for a myocardial infarction is death.
00:00:42.200 | More people...
00:00:43.200 | Now, I would say today, that was 25 years ago, today it's probably not the most common
00:00:51.400 | because advanced cardiac life support is so much better, but it's still strikingly common.
00:00:59.320 | So...
00:01:00.320 | Well, you could say that the best predictor of a heart attack is still a heart attack.
00:01:04.520 | This is just one of those things where we're going to spend a lot of time talking about
00:01:08.160 | things that feel good and feel bad when you change them, right?
00:01:10.760 | Like if you take a person who's not sleeping well, but who thinks they're sleeping well,
00:01:15.160 | and you ask them for a leap of faith, which is, "Hey, give me a month to help you sleep
00:01:19.000 | really well."
00:01:20.000 | Yeah, you're going to feel better.
00:01:21.680 | You might not know it now because you don't know how bad you're sleeping now.
00:01:24.800 | You've become acclimated to this.
00:01:26.400 | But this is not one of those domains, exercise, nutrition, sleep, all those things.
00:01:31.360 | When you do those things better, you feel better.
00:01:34.240 | But I don't want to over-promise on this.
00:01:37.040 | You're not going to feel better in the moment when you fix your lipids, but you'll feel
00:01:41.360 | better when you don't have a heart attack.
00:01:43.720 | So by all this logic, everybody should get their ApoB measured.
00:01:46.880 | How early in life should people do that, starting in their 20s, in their 30s?
00:01:52.840 | Only if you have a family history that is of any concern.
00:01:56.600 | If I could live my life over again, if I knew everything then that I know today, yeah, I
00:02:01.720 | would have had mine measured in my 20s.
00:02:04.640 | I didn't get my ApoB measured for the first time probably until I was in my 40s because
00:02:09.360 | that's, well, yeah, maybe late 30s, early 40s, right?
00:02:15.040 | I had my first calcium scan when I was 35 and I had to beg, borrow, steal to get it
00:02:19.360 | done because everyone was like, why does a 35 year old want to do this?
00:02:23.120 | But I something, I just felt something was wrong given my family history and I'm glad
00:02:28.880 | I did.
00:02:29.880 | I'm glad I did that because I learned something that, that completely changed the direction
00:02:33.320 | of my life.
00:02:34.320 | Okay.
00:02:35.320 | I know my ApoB numbers and that I might be that guy who's up in the, you know, above
00:02:38.040 | a hundred.
00:02:39.040 | So I'm going to get this treated.
00:02:40.040 | That's a promise to myself.
00:02:42.400 | We covered the three major risk factors, which were blood pressure, keeping that in check,
00:02:49.760 | don't smoke and ApoB.
00:02:52.560 | And we've now talked about the things to adjust ApoB levels.
00:02:56.480 | We did not really talk about things to adjust blood pressure.
00:02:59.240 | I'm assuming exercise sits as one of the foremost.
00:03:01.920 | Exercise, nutrition, yeah.
00:03:03.360 | Weight management is a huge one here.
00:03:05.120 | So you know, you take a person who's blood, and this is one of those things where we don't
00:03:09.200 | immediately jump on the pharmacotherapy train with blood pressure, because here there are
00:03:13.560 | side effects sometimes.
00:03:15.640 | And you do have to worry about overshooting.
00:03:18.560 | You don't really have to worry about overshooting a person's lipids.
00:03:21.200 | We do back off if we overshoot, but it doesn't cause a symptom.
00:03:24.760 | There's not a, there's not a short-term immediate risk from doing that.
00:03:28.080 | If you overshoot somebody's blood pressure medication, you trade one problem for another
00:03:32.560 | problem.
00:03:33.560 | They become lightheaded when they get up to pee at night, they fall and bang their head.
00:03:35.880 | That's a devastating consequence, totally unacceptable.
00:03:38.600 | So our goal is to see how much we can lower blood pressure without medication before we
00:03:44.120 | turn to medication.
00:03:45.360 | And let's be clear, the meds today are so much better than they used to be.
00:03:50.560 | Again, there was a day when the side effects of these medicines were miserable.
00:03:55.240 | That's simply not the case today.
00:03:56.240 | I mean, ACE inhibitors, angiotensin receptor blockers, I mean, these things are very well
00:04:01.360 | tolerated, especially the ARBs.
00:04:04.920 | So again, almost anybody can be on these things.
00:04:07.840 | But if we could get a person to lose 10 pounds and exercise every day, we see great effects
00:04:13.440 | with zone two stuff, right?
00:04:14.640 | So kind of the low intensity cardio.
00:04:16.200 | What's, and your recommendation there, I know you talk about this in the book, but are we,
00:04:20.840 | I've thrown out numbers about 150 to 180 minutes per week.
00:04:24.320 | You go a bit higher.
00:04:25.320 | Yeah, we go 180 to 250, 240.
00:04:27.760 | Yeah, I'd like to see three to four hours a week of zone two.
00:04:32.120 | So that's an important piece and sleep is an important piece.
00:04:35.680 | So get the sleep right, get the exercise right.
00:04:38.440 | If you're overnourished, let's correct that problem.
00:04:42.360 | And if all of that doesn't work, and by the way, that works a lot of the time, that works
00:04:47.080 | most of the time.
00:04:48.080 | If that doesn't work, then we've got pharmacotherapy.
00:04:50.160 | There is still a true phenomenon of essential hypertension, which is in individuals for
00:04:54.720 | whom all the fixable stuff has been fixed and they still have high blood pressure.
00:05:00.260 | We still have to medicate those folks.
00:05:02.380 | By the way, there's something that I want to mention here that doesn't get much attention,
00:05:05.640 | but it's so important, which is the effect of high blood pressure on the kidney and also
00:05:10.160 | the brain itself.
00:05:11.160 | We've talked about the brain, we've talked about the heart, but the kidney doesn't get
00:05:13.480 | enough attention.
00:05:15.040 | The kidney is a remarkable organ.
00:05:18.480 | And I think if you're really in this game of trying to live longer, right?
00:05:22.200 | If you think, hey, you know, maybe we'll live 80, 85 years, but if we kind of start doing
00:05:27.920 | all of these other things and really optimizing our behaviors, that could be 95.
00:05:33.240 | Well, you have to start thinking about the capacity of the kidney.
00:05:38.240 | And once the glomerular filtration rate falls below a certain level, you have to be very
00:05:44.880 | careful with how you live your life.
00:05:47.560 | And unfortunately, this is one of those things that is another sort of mistake that's made
00:05:52.280 | in kind of modern medicine, which is we don't pay enough attention to how to measure kidney
00:05:57.000 | function correctly.
00:05:58.000 | We rely very heavily on something called creatinine as opposed to looking at another biomarker
00:06:03.660 | called cystatin C, which is far more accurate.
00:06:06.260 | And we also tolerate too low of a kidney function for a person's age.
00:06:10.820 | So we look at, you know, we might look at someone who's 50, whose kidney function is
00:06:16.200 | at 65% and say, you're totally fine.
00:06:19.940 | Because it's true that at 65% there is no problem.
00:06:23.040 | But you're not thinking, well, if this person has to live another 40 years and this continues
00:06:26.880 | to go down, they're going to potentially be staring down the barrel of needing dialysis
00:06:32.080 | the last five years of their life.
00:06:33.960 | Again, you want to die with compromised kidney function, but never from compromised kidney
00:06:40.160 | function.
00:06:41.160 | In fact, the hazard ratio of all-cause mortality associated with compromised kidney function
00:06:45.040 | is even greater than that of heart disease.
00:06:48.440 | Once you cross that threshold, I mean, lights out.
00:06:51.440 | Once you are needing dialysis, I mean, your risk of death is higher than that of someone
00:06:57.480 | with high blood pressure, smoking, even someone who has cancer.
00:07:00.920 | You have a higher risk of death having end-stage renal disease than you do having cancer.
00:07:04.960 | So the kidney is so sensitive to blood pressure.
00:07:09.800 | This is a tiny organ that on every pump of your heart is getting 20% to 25% of your blood.
00:07:17.400 | So just imagine how sensitive and susceptible it is to elevated blood pressure.
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