When I was in medical school, we had a, and I think I even write about this in the book, we had a pathology lecture where the professor stands up there and he says, "What is the most common presentation of a heart attack?" And you know, us keener first-year med students, hands shoot straight up.

Chest pain. No, that's not the most common. Oh, shoulder pain. Arm radiating down the left arm. No. Shortness of breath. No, no, no. We rattled this off for a few minutes, and he goes, "Death." The single most common presentation for a myocardial infarction is death. More people... Now, I would say today, that was 25 years ago, today it's probably not the most common because advanced cardiac life support is so much better, but it's still strikingly common.

So... Well, you could say that the best predictor of a heart attack is still a heart attack. This is just one of those things where we're going to spend a lot of time talking about things that feel good and feel bad when you change them, right? Like if you take a person who's not sleeping well, but who thinks they're sleeping well, and you ask them for a leap of faith, which is, "Hey, give me a month to help you sleep really well." Yeah, you're going to feel better.

You might not know it now because you don't know how bad you're sleeping now. You've become acclimated to this. But this is not one of those domains, exercise, nutrition, sleep, all those things. When you do those things better, you feel better. But I don't want to over-promise on this.

You're not going to feel better in the moment when you fix your lipids, but you'll feel better when you don't have a heart attack. So by all this logic, everybody should get their ApoB measured. How early in life should people do that, starting in their 20s, in their 30s?

Only if you have a family history that is of any concern. If I could live my life over again, if I knew everything then that I know today, yeah, I would have had mine measured in my 20s. I didn't get my ApoB measured for the first time probably until I was in my 40s because that's, well, yeah, maybe late 30s, early 40s, right?

I had my first calcium scan when I was 35 and I had to beg, borrow, steal to get it done because everyone was like, why does a 35 year old want to do this? But I something, I just felt something was wrong given my family history and I'm glad I did.

I'm glad I did that because I learned something that, that completely changed the direction of my life. Okay. I know my ApoB numbers and that I might be that guy who's up in the, you know, above a hundred. So I'm going to get this treated. That's a promise to myself.

We covered the three major risk factors, which were blood pressure, keeping that in check, don't smoke and ApoB. And we've now talked about the things to adjust ApoB levels. We did not really talk about things to adjust blood pressure. I'm assuming exercise sits as one of the foremost. Exercise, nutrition, yeah.

Weight management is a huge one here. So you know, you take a person who's blood, and this is one of those things where we don't immediately jump on the pharmacotherapy train with blood pressure, because here there are side effects sometimes. And you do have to worry about overshooting. You don't really have to worry about overshooting a person's lipids.

We do back off if we overshoot, but it doesn't cause a symptom. There's not a, there's not a short-term immediate risk from doing that. If you overshoot somebody's blood pressure medication, you trade one problem for another problem. They become lightheaded when they get up to pee at night, they fall and bang their head.

That's a devastating consequence, totally unacceptable. So our goal is to see how much we can lower blood pressure without medication before we turn to medication. And let's be clear, the meds today are so much better than they used to be. Again, there was a day when the side effects of these medicines were miserable.

That's simply not the case today. I mean, ACE inhibitors, angiotensin receptor blockers, I mean, these things are very well tolerated, especially the ARBs. So again, almost anybody can be on these things. But if we could get a person to lose 10 pounds and exercise every day, we see great effects with zone two stuff, right?

So kind of the low intensity cardio. What's, and your recommendation there, I know you talk about this in the book, but are we, I've thrown out numbers about 150 to 180 minutes per week. You go a bit higher. Yeah, we go 180 to 250, 240. Yeah, I'd like to see three to four hours a week of zone two.

So that's an important piece and sleep is an important piece. So get the sleep right, get the exercise right. If you're overnourished, let's correct that problem. And if all of that doesn't work, and by the way, that works a lot of the time, that works most of the time.

If that doesn't work, then we've got pharmacotherapy. There is still a true phenomenon of essential hypertension, which is in individuals for whom all the fixable stuff has been fixed and they still have high blood pressure. We still have to medicate those folks. By the way, there's something that I want to mention here that doesn't get much attention, but it's so important, which is the effect of high blood pressure on the kidney and also the brain itself.

We've talked about the brain, we've talked about the heart, but the kidney doesn't get enough attention. The kidney is a remarkable organ. And I think if you're really in this game of trying to live longer, right? If you think, hey, you know, maybe we'll live 80, 85 years, but if we kind of start doing all of these other things and really optimizing our behaviors, that could be 95.

Well, you have to start thinking about the capacity of the kidney. And once the glomerular filtration rate falls below a certain level, you have to be very careful with how you live your life. And unfortunately, this is one of those things that is another sort of mistake that's made in kind of modern medicine, which is we don't pay enough attention to how to measure kidney function correctly.

We rely very heavily on something called creatinine as opposed to looking at another biomarker called cystatin C, which is far more accurate. And we also tolerate too low of a kidney function for a person's age. So we look at, you know, we might look at someone who's 50, whose kidney function is at 65% and say, you're totally fine.

Because it's true that at 65% there is no problem. But you're not thinking, well, if this person has to live another 40 years and this continues to go down, they're going to potentially be staring down the barrel of needing dialysis the last five years of their life. Again, you want to die with compromised kidney function, but never from compromised kidney function.

In fact, the hazard ratio of all-cause mortality associated with compromised kidney function is even greater than that of heart disease. Once you cross that threshold, I mean, lights out. Once you are needing dialysis, I mean, your risk of death is higher than that of someone with high blood pressure, smoking, even someone who has cancer.

You have a higher risk of death having end-stage renal disease than you do having cancer. So the kidney is so sensitive to blood pressure. This is a tiny organ that on every pump of your heart is getting 20% to 25% of your blood. So just imagine how sensitive and susceptible it is to elevated blood pressure.

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