March 5, 2025 • 38 mins
Dr. Trevor Greene joins Dr. Michael Koren to discuss the effects of inflammation on the cardiovascular system. The two cardiologists talk about biomarkers that have increasing importance: including liporprotein(a) and hsCRP. The doctors finish up with actionable lifestyle changes everyone can implement.Â
Koren's Key Takeaways:
- Inflammation plays a big role in the body
- Chronic inflammation influences cardiovascular disease
- The predictive value of hsCRP is being investigated now
Be a part of advancing science by participating in clinical research.
Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcer (00:00):
Welcome to the MedEvidence! podcast.
This episode is a rebroadcastfrom a live MedEvidence!
presentation.
Dr. Michael Koren (00:06):
So, Trevor, I'm really excited about this
because it's always fun to havea conversation with an old
friend, indeed, and we like tohave an audience share this
concept of two docs just talkingabout a topic and gleaning
information from it.
And, as you know, our wholeMedEvidence platform is based on
that (00:24):
Two knowledgeable doctors talking about something and
having the audience kind ofeavesdrop and then ultimately
ask questions about what theysee and what they perceive.
And that point of perception, Ithink, is so fascinating.
So Trevor and I were justsmiling and when Sharon and
Vicki were doing their intro,they were showing you a couple
(00:47):
of things about what we do, butthey were also looking at this
slide over their shoulders andit's a beautifully attractive
slide with a beautiful heart inthe middle of it.
But Trevor and I look at thisslide and our heart starts to
race because this is a veryabnormal EKG.
So, Trevor, why don't you?
give us some insight on that
Dr. Trevor Greene (01:09):
Well, good afternoon.
Thanks for having me here andcoming out to share this thought
with us.
This EKG is abnormal.
There's a lot of spikes andvalleys and everything else, but
the beautiful thing about it isthat there's a heart holding
everything together.
So if you have a good heart,things will always be together.
Dr. Michael Koren (01:32):
All right, yeah, so when we see something
like this, we don't know if yourelectrolytes are completely out
of whack or you're about tohave a heart attack, all right.
So, as you know, we have amantra for these programs that
there's no such thing as a freelunch, and what we mean by that
is audience participation isextremely important to us.
(01:53):
So to start this process by ashow of hands, who here in the
audience has heard of HSCRP?
Yes, show of hands.
Very few.
Dr. Trevor Greene (02:07):
I don't see any hands at all no, okay.
Oh, there you go, there you go,okay, so All right,
Dr. Michael Koren (02:13):
Not everybody's raising their hands,
so don't bother me, I'menjoying my lunch is the third
option.
Okay.
And question two what is HSCRP?
Just to see what the knowledgebase is before we start.
A blood test and marker forvascular inflammation, a
(02:33):
politically correct way toexpress crap.
Outreach to the underserved CRPcommunity, an acronym for
high-strung, clearly ridiculouspoliticians, or all of the above
.
All of the above, all right.
(02:56):
Who says one Okay?
who says one of the otheranswers.
Dr. Trevor Greene (03:02):
You got your vote already,
Dr. Michael Koren (03:03):
All right.
Well, One is correct, socongratulations on that.
And here's a tough one, whichhas the best ability to predict
heart attacks and strokes ininitially healthy women over 30
years.
Is it LDL cholesterol?
Is it lipoprotein A?
(03:24):
Is it HSCRP?
Is it your high school lover?
Or listening to MedEvidencepodcasts?
So, interestingly, again, thebest ability.
Remember that's a veryimportant word.
So who says it's LDLcholesterol?
(03:45):
Who says?
it's lipoprotein A.
Okay, I'm impressed that peopleeven know what that is.
Yeah, who says HSCRP?
Oh, a lot of hands there.
Okay, they're good test takers.
They're good.
How about your high schoollover?
Now there we go.
Or listening who's listened toMedEvidence podcasts?
No hands yet?
(04:06):
No, we've got a couple, Allright?
Well, the answer is, in fact,HSCRP.
So Trevor and I are going to getinto this a little bit more,
but I mentioned the MedEvidencepodcast a couple of times and
sort of the international leaderin this is a fellow named Paul
Ritger, who I went to medicalschool with, and Paul and I had
a great conversation about thison our MedEvidence podcast that
(04:28):
you should all check out.
I think you'll really enjoy it,and that goes into a lot of
detail.
It also explains how Paul hasreally spent his entire career
studying this issue and he's hadmultiple very, very important
publications, including apublication that showed that if
you measured an HSCRP level in awoman 30 years ago, it would
(04:50):
actually be more predictive ofwhat would happen from a heart
attack and stroke perspectiveover the next 30 years.
So really, really superinteresting stuff.
So, Trevor, I'm going to letyou take center stage here for a
second, so give people justlike a general sense for CRP as
a predictor and help themunderstand that a little bit.
Dr. Trevor Greene (05:10):
Well, you know, when I first started out
actually here in Florida 20years ago about 13 years before
that in Massachusetts theinflammation was a big topic and
for some reason it just seemedto fall below the radar with all
the background noise that we'regetting in terms of cancer and
all the other issues.
(05:31):
But what we've come to realizeis that inflammation is very
important in the human body, andyou can look at it in terms of
the way you look at wear andtear.
Your brakes wear and tear yourmuffler wear and tear.
So too does the rest of yourbody, and as you get more and
(05:52):
more birthdays and as you areexposed to more and more bad
stuff from the environment,inflammation builds up in the
body.
Dr. Michael Koren (06:01):
Right, and then we have actually statistics
to support that.
Dr. Trevor Greene (06:07):
Because we tell you, make sure that that
LDL is as low as possible.
We want to figure out, togetherwith the LDL and together with
the CRP, what numbers that youneed to pay attention to.
So what?
This slide shows very clearlythat if you're LDL, that's the
low density lipid protein,that's the one that is
(06:28):
supposedly the bad guy.
If that's too high, greaterthan 130 milligrams per
deciliter, and the C-reactiveprotein, if it is greater than
two, then your cardiovascularmortality, the risk of getting a
stroke, the risk of heartdisease, increases exponentially
.
Dr. Michael Koren (06:48):
Yeah, so that's this point right here.
So when both the LDL and theCRP are elevated, that's bad
news and this tells you.
Your risk goes up about 70%.
And the flip side is that whenyour CRP is lower, even if your
LDL is a little bit higher, yourrisk does not go up that much,
(07:09):
so it's an interesting slide.
And how about statin intolerantpatients?
Help them understand that alittle bit.
Dr. Trevor Greene (07:16):
Well, statins .
Statins is a sexy drug.
It's been out for a while.
Unfortunately, if you go to theinternet, you're going to see
good things about statins.
You're going to see bad thingsabout statins and it's not
unusual for me to have one of mypatients say to me I'm not
going to take a statin.
I heard bad things aboutstatins but, truth be told,
(07:38):
statins have had a big shift inprotection for heart disease,
especially when you come tocontrol the cholesterol,
especially getting the LDLcholesterol under control.
So it's something that youshould discuss with your
physician and keep an open mindbecause, yes, there are side
(07:59):
effects, as there are sideeffects with any drug, any
medicine, and some people can'ttake them because of the
achiness and that kind of stuff,and there are alternatives.
But it is a very importantconversation that you should
have with your physician.
Dr. Michael Koren (08:12):
Right, and statins, as you know, lower
cholesterol, particularly LDLcholesterol, but they also lower
CRP, and a lot of the otherdrugs that lower LDL cholesterol
don't lower CRP, so that is aunique property of statins, and
then just tell people about whatyou consider an optimal level
(08:32):
for these numbers and how theyshould maybe communicate with
their physicians about it.
Dr. Trevor Greene (08:37):
Yeah well, once you get your blood work
done from your primary carephysician or your cardiologist
or both, you'll be throwingthese numbers out at you and the
goal for most people who havecoronary artery disease or
diabetes or hypertension or acombination of all the above,
the aim is to get that low, theLDL cholesterol as low as
(08:58):
possible, and that number for usis less than 100.
And if you can get it below 70,that also is optimal.
And the CRP, of course, we wantthat to be less than 1.
Understanding, if your CRP isgreater than 2, you're in bad
land.
You want to get back to asituation where your CRP is less
(09:19):
than 1.
Dr. Michael Koren (09:20):
Right.
And the other point here that Ithink is really valuable for
people to know is that LDLcholesterol response to
treatment is very predictable.
So if we have a patient thathas an LDL of 130 and we put
them on rosuvastatin ortorvastatin, we know they're
going to be around 70 after wedo that.
We're pretty sure that we'llget them in that range, so it's
(09:42):
pretty predictable.
But hsCRP is not
Dr. Trevor Greene (09:45):
Right That's exactly right.
Dr. Michael Koren (09:47):
And we don't have great ways for lowering
that to date and we're going toget more into that concept.
But the reason the focus hasbeen on LDL for many years is
because we can reliably bringthat down.
Dr. Trevor Greene (09:59):
Yeah, and the reason for that too is because
normally you usually look wherethe light is.
If you drop your dollar billhere and the light is over there
, the human nature is to tendtowards where the light is.
The point there is that we hadsomething to treat the LDL, but
we really don't have somethingyet to niche on to get that CRP
(10:20):
down.
But we're working on it andthat's why it's important that
we have studies.
That's the important way wehave groups like this and we are
very fortunate to have goodresearch people notwithstanding
Dr.
Koren, of course in town toguide us through these kind of
studies that are necessary andthey are no harm to you.
(10:40):
You turn up, you have yourblood work done and then we go
behind the scenes and literallysort out the value of having
these tests done.
Dr. Michael Koren (10:52):
So, out of curiosity now, who in the
audience has had their CRPmeasured?
I'm just really curious aboutit.
Show of hands, yes, have youhad your CRP measured?
Very few interesting, no.
Dr. Trevor Greene (11:03):
I'm not sure if that is a reflection of you
or your physician, but eitherway.
But now you'll go back to yourphysician and say, hmm,
Exactly who says who is no forCRP?
measured, that is a whole crowd.
Okay.
Dr. Michael Koren (11:18):
Well, there's still people that haven't
raised their hands, so that mustbe excuse me, I'm still eating
my lunch, okay, all right.
So, Trevor, just kind of walkthrough.
Even though we can't reliablyget hsCRP levels down, there are
some things that kind of moveit in the right direction.
Dr. Trevor Greene (11:38):
These are the favorites.
These are the five favorites.
Weight loss I discoveredsomething very interesting a
couple of nights ago.
I'm not sure what it waslistening to, but I come to
found out that the 74% there's apretty impressive number 74% of
the American population isobese.
Dr. Michael Koren (12:01):
That was the Super Bowl commercial.
Dr. Trevor Greene (12:02):
Ah, that's correct.
Him and hers.
Yeah, yeah, that's right.
Yeah, that's right.
Dr. Michael Koren (12:06):
It might be a slight exaggeration,
but I was.
I was impressed by that.
Yeah, I would say whoa.
is that true?
Now I happen to know that inthe in the in the third world,
particularly countries, forexample, where I'm from,
Barbados, where diabetes is veryrampant, obesity is a big issue
, and in a place like Barbadosyou can have 80% of the
(12:30):
population who are obese.
But what do we mean by obeseBMI body mass index?
You have to have some kind of areference BMI which is worked
out on the basis of your heightand your weight is above 25,
then you are mildly obese, up to30, moderately obese and
(12:52):
greater than 30, we're talkingabout morbidly obese.
So that's a, that's a.
That's a flag.
Getting and staying at 25 is noteasy because of our diet.
So that leads me into diet.
What is a good diet?
Now, if you break again to theinternet and social media, where
(13:13):
we all are, there's a varietyof things that you can do there
paleo, keto, I mean.
You could spend a wholelifetime trying to figure out
what the best diet is, andthere's a lot of research and
there's a lot of myths and a lotof fantasies out there.
But the two things that youhave to pay attention to in your
diet is carbohydrates, whichwould be sugar, and salt.
(13:36):
So I usually submit to mypatients the ones who I get
around with a lot, and I getaround with a lot of my patients
and I say to them if you wantto live to be as old as
Methuselah, the diet that youshould have is one that has no
salt and no sugar.
And they say what do I do about taste?
Dr. Trevor Greene (14:01):
I still have a practice, so they do come back
to me.
I say it lovingly, but thetruth is the.
The bedrock of diet really isto cut back as much as you
possibly can on your freecarbohydrate intake.
Low calorie intake is probablythe best way to start.
(14:22):
I happen to like theMediterranean diet because it
gives you a better taste.
There's a lot about it that isgood, and so that is something
that you should discuss withyour, with your physician.
Exercising, the one of thebeautiful things I I once heard
about aspirin.
(14:42):
Aspirin is good and I and I Imight have stole this from you,
Michael, okay.
Well, um, in terms ofexercising the, the when you
take your blood pressuremedicines or you take your
cholesterol medicines, or youtake your rheumatoid medicines,
(15:02):
one of the best ways to get thatmedicine to work, to get your
blood pressure down, to get yourglucose down, one of the best
ways to get it to work is totake that medicine for a
five-day walk and then take it.
Exercise Now.
Exercise should be somethingthat you enjoy.
(15:23):
If you're like me and your wifeis beating up on you at seven
o'clock at night because you'renot going to the gym with her.
That is not the kind ofexercise that you want.
Dr. Michael Koren (15:32):
That's what you're saying publicly is the
reason she's beating on you.
Dr. Trevor Greene (15:36):
Publicly Exercise, but you've got to
enjoy the exercise.
If you can find that form ofexercise that you enjoy, you're
going to accrue a much betterbenefit from it than if you're
doing it as another chore of theday, and the exercise does not
have to be really vigorous, andyou don't want to look like
(15:56):
Arnold Schwarzenegger.
What you want to do issomething that will give you
good repetition.
It is part of your philosophyof what a good day is, and you
do it on a regular basis.
The unfortunate thing aboutexercise is that you can't store
it, so it doesn't matter howmuch you do today, it doesn't
(16:17):
come for tomorrow.
That's the sad part of it all,but you don't have to be brutal
about it either.
It has to be repetitious andcontinuous and something that
you enjoy, and smoking is ano-brainer.
Smoking increases inflammationin the body in a very big way
and, interestingly enough, thenext thing that we're dealing
(16:41):
with, particularly in the youngpopulation most of you guys are
here would have grandchildrenand great-grandchildren that
generation.
You call them all sorts ofnames Zs and Ys and Ks and
whatever else but their biggestproblem is not cigarettes.
Like you knew when you weregrowing up, their biggest
problem now for smoking isactually vaping.
(17:02):
Vaping is a big problem becauseit is a highly sophisticated
way of getting nicotine in thesystem.
It's very addictive.
So if your grandkids come andthey say to you, oh, but
grandmommy and granddad, I don'tsmoke, I'm into vaping, and you
, oh, my God, you got rid of thetar, yes, but the inflammatory
(17:33):
consequences of smoking andvaping is still there and with
all the vaping tastes that areout there, it becomes very
addictive.
Aspirin Aspirin has gone fromone end of the spectrum to the
other and, like I said, the bestthing you can do with aspirin
is to take it for a five-milewalk and it will work even
better.
As we get older.
We've got to be very carefulwith aspirin and bleeding
(17:55):
aspirin and bruising.
It's tough.
But low-dose aspirin, we doknow, is beneficial and that's
something that you shoulddiscuss with your physician to
the extent that you might betaking other medicines as well.
So there's no real one hardcorestatement on aspirin, but
low-dose aspirin is also verygood.
Dr. Michael Koren (18:15):
Yeah, all excellent points.
I would just add a couple ofquick things on aspirin.
What we learned over time is ifyou can get to 70 years old and
have absolutely no evidence ofatherosclerosis, aspirin doesn't
help anymore because you'rejust not at high risk.
But that means you have nocoronary calcium, you really
(18:35):
have no atherosclerosis.
But if you're in that moderaterisk category, even if you
haven't had a heart attack,aspirin helps.
And of course, if you had aheart attack, then you should
definitely be on something likeaspirin or another type of blood
thinner, and I loved yourconcept of taking a pill for a
five-minute walk.
Let's go for 10 minutes, how's?
Dr. Trevor Greene (18:53):
that 10 minutes, there you go.
Dr. Michael Koren (18:57):
And getting results from exercise is all
about doing something you likeand getting it in your schedule.
It really comes down to that,all right.
So I think we covered all thisreally well and there's just
some numbers for everybody tosee that all these things have
been scientifically validated.
So, if you exercise more thanonce a week, how much exercise
(19:18):
do you recommend to yourpatients as a target?
Dr. Trevor Greene (19:22):
Well, the number that I have to deal with
personally, because my wifethrows this number, at me is
that we should get at least10,000 steps a day.
10,000 steps a day is hard, it'shard.
I'm up and about doing my stuffin the lab and running around.
I seldom use the elevator, Irun the stairs, things like that
(19:44):
.
I don't try to park too closeto the establishment.
You park in the parking lot andwalk.
You can get in your steps inthat kind of a nebulous way.
And uh, there was a recent Isaw a recent study that showed
that 7 000 is about optimal,primarily because 10 000 is just
(20:05):
too much.
And if you, if you ask someperson to do 10 000, after a
while they get so dejected thatthey can't get there that they
just give it up, whereas if yousay, you know what, let's go for
seven, and if you get the five,that's still better than zero.
Dr. Michael Koren (20:23):
So exercise that's the number and steps is
one element of exercise.
Obviously, there are differentways of exercising, so if you're
swimming, that's not stepsnecessarily, or?
you're biking.
I like to tell my patients totry to do two hours of aerobic
exercise per week and try tomake those sessions at least 20
(20:44):
minutes long.
So personally, I'm pretty goodat doing at least 30 minutes
four days a week, and I like togo to the gym, ride the bike and
that's what works for me.
But finding the thing that youlike to do is so important, and
it could be collecting seashellson the beach, it could be
working in the garden, and aslong as you're sort of moving
(21:06):
around getting up and down, thatwould count.
It doesn't really matter whatyou do, but doing it for two
hours a week, 30-minute sessions, to me is really what you
should be targeting, and I thinkit's pretty clear that if
you're smoking now, please workwith your physician to get off
of it, all right.
So you want to jump into this alittle bit in terms of exactly
(21:30):
the mechanism by which CRP leadsto cardiac problems exactly the
mechanism by which CRP leads tocardiac problems.
Dr. Trevor Greene (21:37):
Yeah, we don't want to bog you down with
too much clinical detail, butcertainly the inflammation
causes the reactions in yourbody that will promote
inflammation, and they're very,very complex pathways in the
body and we go after all of themin our different ways of coming
(21:58):
at it.
The big thing really would becoagulation and clotting.
Clotting is a big issue,particularly if there is anyone
in the room who might besuffering from atrial
fibrillation and your physicianputs you on your blood thinners.
That's where that plays intothis whole complex, but it's
very sophisticated.
The main thing really would beto make sure that you get your
(22:24):
hsCRP high-sensitivity CRP andgo from there work with your
physician.
Dr. Michael Koren (22:31):
Yeah, and this is an area of confusion for
some people.
So hsCRP was actually firstdiscovered because it's
expressed in extremely highlevels when people come in with
pneumonia, particularlypneumococcal pneumonia, and it's
thought that this is part ofthe body's mechanism to identify
(22:51):
a foreign invader and to helpthe immune system attack it.
And we are probably built tohave this response because of
prehistoric days when we didn'thave modern medicine and this is
all we had.
But if you had to compare hsCRPto penicillin in terms of
fighting bacteria, you're goingto choose penicillin and, of
(23:14):
course, hsCRP, Although it mayhave some beneficial effects
with regard to responding toinfections in modern times, it's
probably a net negative because, as Dr.
Greene mentioned, it leads toblood clots, it leads to what we
call inflammatory cytokines,which are these chemicals that
(23:35):
get the immune system all hotand heavy, and then there's
something called the complementpathway that gets your
antibodies all fired up.
So by getting your immunesystem fired up is not
necessarily good for your heartand blood vessels
Dr. Trevor Greene (23:48):
Or like a good thing going bad.
Dr. Michael Koren (23:49):
Exactly and again this also summarizes it
that short-term that there couldbe some benefit for infection
or injury, but long-term there'smuch more harm and frankly, in
modern society.
The long-term issues kill many,many more people than the
short-term issues, and we havelots of good ways for dealing
(24:11):
with short-term infections.
So we don't necessarily needthis system to kick in, and
these are just a little bit moresophisticated slides, but it
just tells you all the differentways.
I'll turn this way.
These are all the differentcells in the body that are
responsible for inflammatoryreactions and the cytokines are
(24:34):
the chemicals that amplify thatresponse.
And the reason we're bringingthis up is because a lot of the
research that we're doing now isspecifically targeting
cytokines, Not so much the CRP,which is sort of the end result
of the inflammatory cascade orthe immediate reaction, as the
case may be, but getting veryspecific, because there are now
(24:58):
dozens of cytokines that havebeen identified and we think by
blocking specific cytokines thatare important in terms of
cardiac and vascularinflammation, we can come up
with that magic bullet that doeswhat it needs to do for the
heart and blood vessels withoutbothering the immune system when
(25:19):
it comes to other things.
So we're particularly excitedabout this whole concept.
I don't know if you have anycomments about that.
And there's our pictureclose-up.
Good job to our presentationstaff for getting such a
beautiful picture.
I appreciate that.
Dr. Trevor Greene (25:36):
I think it helps me understand it at least.
Dr. Michael Koren (25:41):
All right back to audience questions.
So which of these cytokines iscurrently under investigation
for its potential to reducevascular inflammation?
If anybody gets this right,I'll be impressed.
Vascular information Now.
If anybody gets this right,I'll be impressed.
So interleukin 1, I should meaninterleukin 6,.
(26:08):
Tnf-alpha or interleukin 10.
Show of hands who thinks it's 1?
Okay.
Who's going to raise their handfor this question?
Who thinks it's 2?
We get 1, okay.
And who thinks it's three, okay, interesting.
Well, there are TNF-alpha drugson the market, but that's a
cytokine, that's more forgeneral inflammation, for
example rheumatoid arthritis.
(26:28):
We have TNF-alpha drugs forinflammatory bowel disease, for
example Crohn's disease.
Interleukin-10 is interesting,but the actual answer is
interleukin-6.
And, as I mentioned, I wouldhave been surprised if anybody
got that.
We've looked at other of thesecytokines over the years and
we're really, really excitedabout this particular one
(26:49):
because we think this is themost specific trigger for
vascular inflammation and as wespeak, we're doing studies
looking specifically at blockinginterleukin-6 and seeing
whether or not people do betterfrom a heart disease standpoint.
So you want to give a littleLp(a)?
Dr. Trevor Greene (27:07):
Yeah well.
Lp(a) lipoprotein AnyAfrican-Americans in the crowd?
Yeah, definitely Be a.
I feel like high levels oflipoprotein kind of plague the
African-American population,primarily because of genetics.
The only way you can fix thatis if you change your parents,
and that would be a littletricky.
(27:27):
So once you're stuck with that,we know that.
One in five people around theworld.
Dr. Michael Koren (27:31):
My kids have been trying that.
It hasn't worked
Dr. Trevor Greene (27:33):
It hasn't quite worked.
So that is another marker thatyour physician can use to look
to see if you're particularlyhaving trouble getting your
lipid levels as we call them asa general group under control.
Dr. Michael Koren (27:52):
Yeah, we're particularly interested in this
because we have a number ofmolecules in clinical research
that actually lowerlipoprotein(a) up to 95%, and
lipoprotein(a) is responsiblefor vascular inflammation.
So it's one of the factors thatincreases your hsCRP and, as Dr.
Greene mentioned, it's veryhighly concentrated in certain
(28:13):
families.
So if you have a risk of heartdisease in your family, so if
you have a risk of heart diseasein your family say, a mother, a
father or brother or sister oran uncle or aunt who died before
age 65 of cardiovasculardisease or had a heart attack or
stroke before 60 you shouldknow your Lp(a) and we're happy
to do that for free at theresearch office and,
(28:34):
interestingly, most people haveLp(a)s that are what we call
normal, which would be below 50milligrams per deciliter, but we
see some people with thisfamily history that can have
Lp(a) levels of 500, just hugeelevations.
So that's something you shouldknow and this connection between
Lp(a) and hsCRP is somethingthat we're studying now and we
do have some really, reallyinteresting clinical trials to
(28:57):
lower lipoprotein( a) if we findthat you have high levels.
Dr. Trevor Greene (29:00):
So you've just became a very, very
well-educated audience.
So when you speak to yourprimary care physician or your
cardiologist and you mentionLp(a), you might very well hear
what are you talking about.
What is that?
And you'll be able to say ohwell, I know about that stuff, I
heard all about it, so it'sgood stuff.
Dr. Michael Koren (29:20):
Yeah, three years ago, when we started
teaching people about LP(a) andhsCRP, most of the physicians
really didn't even know what itwas, and more and more doctors
are now learning it and we'refinding more and more doctors
very open to this message, butit's still not a standard in
practice, although a lot of usagree that it should be
Dr. Trevor Greene (29:41):
and that's the beauty of having stuff like
this, where we bring thatinformation directly to you, so
to speak, so that we can kind ofexpand it more, because,
depending on your relationshipwith your physician, you might
actually get to spend that extraminute or two thinking about
ways of trying to control thatcholesterol that you just simply
(30:01):
can't get control, or thestatins might not be working the
best, and then you're runningfrom one statin to the next.
Are you going on to the new?
You say, could we take a lookat our Lp(a)?
You know my old uncle Right?
Dr. Michael Koren (30:15):
right, right, exactly.
Dr. Trevor Greene (30:17):
That's the kind of sense that we want to
pass on.
Dr. Michael Koren (30:20):
Yeah, and here's a little pearl that,
again, a lot of physicians donot know.
So when you go to Quest orLabCorp one of these places and
you get your LDL measured, it'smeasured indirectly.
It's not actually being measureddirectly, and within that
measurement is actually Lp(a),because Lp(a) is a form of LDL
cholesterol.
So you might have a slightlyelevated level of LDL and you
(30:44):
may not think that much about it, but if that LDL slight
elevation is due to Lp(a),that's a big threat.
It's a really big threat, andso doctors don't always
understand that directmeasurement of LDL doesn't show
lipoprotein(a), but most peoplewho get their LDL measured are
lumping all the forms of.
LDL in the same measurement andnot breaking it down.
(31:06):
And you don't even know howmuch of that is Lp(a).
Dr. Trevor Greene (31:10):
Which brings up the golden code; you see what
you look for.
You recognize what you know.
Right, there you go, exactly.
If you're not looking for it,then it's there.
You're not going to see it,
Dr. Michael Koren (31:20):
right and we call it the triple threat,
because it's pro-atherogenic,meaning it causes plaques, it's
pro-thrombotic, which means itcauses clots, and it's
pro-inflammatory, which createsirritation and other problems
within your blood vessels.
And, as mentioned, Lp(a) testsare inexpensive.
(31:42):
They can be ordered by anyphysician and more and more
doctors are adding it as part oftheir standard lipid panel, but
it usually is not in the panelunless the doctor asks for it
specifically.
Right, and anybody here in theaudience just let us know and
we'll do it for you for free.
So we'll do it at the researchoffice, we'll set a time for you
(32:03):
to come over and it's simpleand you'll know what you're
dealing with.
And so we're going to kind ofend with talking a little bit
about clinical trials and thesedata just absolutely fascinate
me, Trevor, is when you go topeople in either US or Europe
who have never been exposed to aclinical trial just general,
(32:25):
normal people in the populationand you say, do you have any
interest in participating in aclinical trial?
Just ask that question.
Surveys have shown between 31%and 50%.
On average, about 38% to 40%say they have interest.
In Europe it's actually alittle less than the US.
For whatever reasons it is.
Yeah, interestingly.
(32:46):
But if you go to somebody that'sdone a clinical trial before
and you say, will youparticipate in a second clinical
trial, over 97% say yes.
In our centers here inJacksonville it's 99%.
So how many things in life canyou say that there's a lot of
skepticism the first time youtry it, but once you've been
(33:07):
exposed to it you become a bigbeliever and supporter of it.
Not too many things, not verymany things.
Yeah, and so I find thisfascinating and it's also why we
want to get the message out, tohelp people at least have some
experience with this, becauseit's also why we want to get the
message out to help people atleast have some experience with
this, because it's a verynurturing process and people
(33:27):
learn a lot from being in aclinical trial and I believe
that there's a lot of valuethat's derived in multiple
different ways.
All right, so then we have ourMedEvidence! platform.
I think we had a couple ofpeople that raised their hands
looking at it and again, it'skind of like Trevor and I just
talking about it.
We have now online lots ofdiscussions with people about
the issues of the day and youcan decide what you want to
(33:50):
glean from it, but there'salways going to be insights.
So a couple of the MedEvidence!podcasts that we've done
recently I encourage you to lookat is one with Jerome Adams.
I don't know if you recognizethis, but Jerome Adams was
actually the Surgeon Generalduring the first Trump
administration, so he workedclosely with Mike Pence and he
was part of the first Trumpadministration and he and I had
(34:13):
a wonderful podcast together,wonderful podcast together
Recently.
This is kind of interesting,just the timing of it is that
the last public interview thatTony Fauci did before he got his
get out of jail free card fromJoe Biden was with me in
MedEvidence! so it was just acoincidence.
But Tony and I had a niceconversation about his career,
(34:37):
which is really a spectacularcareer.
It's just mind-boggling howmany things he did during the
course of his career.
That kind of got lost in allthe politics.
But if you want to find outwhat his opinion is about where
COVID-19 came from or did hemake any mistakes or things he
would do differently, check outthe podcast and we say hero or
(34:57):
villain.
I find this so fascinating,Trevor, when I tell people check
out the podcast, they alreadyhave these ingrained opinions
about Tony.
Fauci mostly based on politicsand have never really heard him
speak as a physician.
Check it out.
I'd be curious to see what yourreaction is.
Dr. Trevor Greene (35:17):
The quote that goes there, and you notice
I'm giving you these littlequotes: Perception sometimes is
more powerful than truth,
Dr. Michael Koren (35:23):
exactly.
Yep, all right, that's spot on.
And then another one that we didthat was interesting was with a
local investigator and a goodfriend, Bharat Misra.
He's done programs here with me, he's a gastroenterologist, and
we talked about this concept ofhaving warning labels on
alcohol, and you might know thatthe surgeon general, before the
(35:44):
change in administrations,submitted to Congress a proposal
to put warning labels onalcohol because alcohol is
associated with higher risk forcertain cancers.
But in our world we thinkalcohol probably has a slight
beneficial effect for coronarydisease.
So me as a cardiologist andBharat as a gastroenterologist
had discussion about whether ornot there should be warning
(36:05):
labels on alcohol.
So people have enjoyed thatpodcast.
And then, finally, as wementioned, there are some
ongoing studies in our communitythat are looking at the concept
of inflammation, and just letanybody here know that you're
interested and we'll get youinvolved.
Or if you have a friend orfamily member who you think
might benefit, we'll get youinvolved.
(36:27):
You know so, for example,people that have had a diagnosis
of heart disease may not evenknow what their CRP is, and we
have a study that's just lookingat your numbers.
Help you look at your numbersand understand whether or not
the average person in thecommunity is elevated or not.
So very simple study be anintroduction into clinical
trials and I think you'll enjoyit.
(36:47):
And then we're doing moresophisticated studies.
As I mentioned, we're lookingspecifically at blocking IL-6.
And if you look at the podcastthat I did with Dr.
Paul Ridker, you get a lot moredetails about that particular
approach.
But that's a very sort ofcutting-edge research to see if
a new monoclonal antibody willprotect people against the
(37:07):
effects of IL-6.
And my final word before we getto questions is just sign up.
We have about 100,000 peoplenow that are part of our overall
email and podcast universe.
It's free information.
There's no obligation.
We protect your information.
We never sell your information.
So it's a nice opportunity foryou to just be exposed to people
(37:30):
that will give you objectiveinformation.
We're not trying to sell aweight loss drug.
We're not trying to sell oursupplements.
Sell a weight loss drug, we'renot trying to sell our
supplements.
We're not trying to sell ourcrazy diet book or we're not
trying to either promote or dissvaccines.
We're just trying to get to thetruth of the matter.
And so I think you'll find itinteresting and we'd encourage
(37:51):
you to sign up, and it's as easyas just taking the sheet in
front of you writing your nameand email address or phone
number, and that will get youinto the community and hopefully
get you more involved in whatwe're doing in clinical research
.
Announcer (38:02):
Thanks for joining the MedEvidence! podcast.
To learn more, head over toMedEvidence.
com or subscribe to our podcaston your favorite podcast
platform.
Welcome to the MedEvidence! podcast.
This episode is a rebroadcastfrom a live MedEvidence!
presentation.
Dr. Michael Koren (00:06):
So, Trevor, I'm really excited about this
because it's always fun to havea conversation with an old
friend, indeed, and we like tohave an audience share this
concept of two docs just talkingabout a topic and gleaning
information from it.
And, as you know, our wholeMedEvidence platform is based on
that (00:24):
Two knowledgeable doctors talking about something and
having the audience kind ofeavesdrop and then ultimately
ask questions about what theysee and what they perceive.
And that point of perception, Ithink, is so fascinating.
So Trevor and I were justsmiling and when Sharon and
Vicki were doing their intro,they were showing you a couple
(00:47):
of things about what we do, butthey were also looking at this
slide over their shoulders andit's a beautifully attractive
slide with a beautiful heart inthe middle of it.
But Trevor and I look at thisslide and our heart starts to
race because this is a veryabnormal EKG.
So, Trevor, why don't you?
give us some insight on that
Dr. Trevor Greene (01:09):
Well, good afternoon.
Thanks for having me here andcoming out to share this thought
with us.
This EKG is abnormal.
There's a lot of spikes andvalleys and everything else, but
the beautiful thing about it isthat there's a heart holding
everything together.
So if you have a good heart,things will always be together.
Dr. Michael Koren (01:32):
All right, yeah, so when we see something
like this, we don't know if yourelectrolytes are completely out
of whack or you're about tohave a heart attack, all right.
So, as you know, we have amantra for these programs that
there's no such thing as a freelunch, and what we mean by that
is audience participation isextremely important to us.
(01:53):
So to start this process by ashow of hands, who here in the
audience has heard of HSCRP?
Yes, show of hands.
Very few.
Dr. Trevor Greene (02:07):
I don't see any hands at all no, okay.
Oh, there you go, there you go,okay, so All right,
Dr. Michael Koren (02:13):
Not everybody's raising their hands,
so don't bother me, I'menjoying my lunch is the third
option.
Okay.
And question two what is HSCRP?
Just to see what the knowledgebase is before we start.
A blood test and marker forvascular inflammation, a
(02:33):
politically correct way toexpress crap.
Outreach to the underserved CRPcommunity, an acronym for
high-strung, clearly ridiculouspoliticians, or all of the above
.
All of the above, all right.
(02:56):
Who says one Okay?
who says one of the otheranswers.
Dr. Trevor Greene (03:02):
You got your vote already,
Dr. Michael Koren (03:03):
All right.
Well, One is correct, socongratulations on that.
And here's a tough one, whichhas the best ability to predict
heart attacks and strokes ininitially healthy women over 30
years.
Is it LDL cholesterol?
Is it lipoprotein A?
(03:24):
Is it HSCRP?
Is it your high school lover?
Or listening to MedEvidencepodcasts?
So, interestingly, again, thebest ability.
Remember that's a veryimportant word.
So who says it's LDLcholesterol?
(03:45):
Who says?
it's lipoprotein A.
Okay, I'm impressed that peopleeven know what that is.
Yeah, who says HSCRP?
Oh, a lot of hands there.
Okay, they're good test takers.
They're good.
How about your high schoollover?
Now there we go.
Or listening who's listened toMedEvidence podcasts?
No hands yet?
(04:06):
No, we've got a couple, Allright?
Well, the answer is, in fact,HSCRP.
So Trevor and I are going to getinto this a little bit more,
but I mentioned the MedEvidencepodcast a couple of times and
sort of the international leaderin this is a fellow named Paul
Ritger, who I went to medicalschool with, and Paul and I had
a great conversation about thison our MedEvidence podcast that
(04:28):
you should all check out.
I think you'll really enjoy it,and that goes into a lot of
detail.
It also explains how Paul hasreally spent his entire career
studying this issue and he's hadmultiple very, very important
publications, including apublication that showed that if
you measured an HSCRP level in awoman 30 years ago, it would
(04:50):
actually be more predictive ofwhat would happen from a heart
attack and stroke perspectiveover the next 30 years.
So really, really superinteresting stuff.
So, Trevor, I'm going to letyou take center stage here for a
second, so give people justlike a general sense for CRP as
a predictor and help themunderstand that a little bit.
Dr. Trevor Greene (05:10):
Well, you know, when I first started out
actually here in Florida 20years ago about 13 years before
that in Massachusetts theinflammation was a big topic and
for some reason it just seemedto fall below the radar with all
the background noise that we'regetting in terms of cancer and
all the other issues.
(05:31):
But what we've come to realizeis that inflammation is very
important in the human body, andyou can look at it in terms of
the way you look at wear andtear.
Your brakes wear and tear yourmuffler wear and tear.
So too does the rest of yourbody, and as you get more and
(05:52):
more birthdays and as you areexposed to more and more bad
stuff from the environment,inflammation builds up in the
body.
Dr. Michael Koren (06:01):
Right, and then we have actually statistics
to support that.
Dr. Trevor Greene (06:07):
Because we tell you, make sure that that
LDL is as low as possible.
We want to figure out, togetherwith the LDL and together with
the CRP, what numbers that youneed to pay attention to.
So what?
This slide shows very clearlythat if you're LDL, that's the
low density lipid protein,that's the one that is
(06:28):
supposedly the bad guy.
If that's too high, greaterthan 130 milligrams per
deciliter, and the C-reactiveprotein, if it is greater than
two, then your cardiovascularmortality, the risk of getting a
stroke, the risk of heartdisease, increases exponentially
.
Dr. Michael Koren (06:48):
Yeah, so that's this point right here.
So when both the LDL and theCRP are elevated, that's bad
news and this tells you.
Your risk goes up about 70%.
And the flip side is that whenyour CRP is lower, even if your
LDL is a little bit higher, yourrisk does not go up that much,
(07:09):
so it's an interesting slide.
And how about statin intolerantpatients?
Help them understand that alittle bit.
Dr. Trevor Greene (07:16):
Well, statins .
Statins is a sexy drug.
It's been out for a while.
Unfortunately, if you go to theinternet, you're going to see
good things about statins.
You're going to see bad thingsabout statins and it's not
unusual for me to have one of mypatients say to me I'm not
going to take a statin.
I heard bad things aboutstatins but, truth be told,
(07:38):
statins have had a big shift inprotection for heart disease,
especially when you come tocontrol the cholesterol,
especially getting the LDLcholesterol under control.
So it's something that youshould discuss with your
physician and keep an open mindbecause, yes, there are side
(07:59):
effects, as there are sideeffects with any drug, any
medicine, and some people can'ttake them because of the
achiness and that kind of stuff,and there are alternatives.
But it is a very importantconversation that you should
have with your physician.
Dr. Michael Koren (08:12):
Right, and statins, as you know, lower
cholesterol, particularly LDLcholesterol, but they also lower
CRP, and a lot of the otherdrugs that lower LDL cholesterol
don't lower CRP, so that is aunique property of statins, and
then just tell people about whatyou consider an optimal level
(08:32):
for these numbers and how theyshould maybe communicate with
their physicians about it.
Dr. Trevor Greene (08:37):
Yeah well, once you get your blood work
done from your primary carephysician or your cardiologist
or both, you'll be throwingthese numbers out at you and the
goal for most people who havecoronary artery disease or
diabetes or hypertension or acombination of all the above,
the aim is to get that low, theLDL cholesterol as low as
(08:58):
possible, and that number for usis less than 100.
And if you can get it below 70,that also is optimal.
And the CRP, of course, we wantthat to be less than 1.
Understanding, if your CRP isgreater than 2, you're in bad
land.
You want to get back to asituation where your CRP is less
(09:19):
than 1.
Dr. Michael Koren (09:20):
Right.
And the other point here that Ithink is really valuable for
people to know is that LDLcholesterol response to
treatment is very predictable.
So if we have a patient thathas an LDL of 130 and we put
them on rosuvastatin ortorvastatin, we know they're
going to be around 70 after wedo that.
We're pretty sure that we'llget them in that range, so it's
(09:42):
pretty predictable.
But hsCRP is not
Dr. Trevor Greene (09:45):
Right That's exactly right.
Dr. Michael Koren (09:47):
And we don't have great ways for lowering
that to date and we're going toget more into that concept.
But the reason the focus hasbeen on LDL for many years is
because we can reliably bringthat down.
Dr. Trevor Greene (09:59):
Yeah, and the reason for that too is because
normally you usually look wherethe light is.
If you drop your dollar billhere and the light is over there
, the human nature is to tendtowards where the light is.
The point there is that we hadsomething to treat the LDL, but
we really don't have somethingyet to niche on to get that CRP
(10:20):
down.
But we're working on it andthat's why it's important that
we have studies.
That's the important way wehave groups like this and we are
very fortunate to have goodresearch people notwithstanding
Dr.
Koren, of course in town toguide us through these kind of
studies that are necessary andthey are no harm to you.
(10:40):
You turn up, you have yourblood work done and then we go
behind the scenes and literallysort out the value of having
these tests done.
Dr. Michael Koren (10:52):
So, out of curiosity now, who in the
audience has had their CRPmeasured?
I'm just really curious aboutit.
Show of hands, yes, have youhad your CRP measured?
Very few interesting, no.
Dr. Trevor Greene (11:03):
I'm not sure if that is a reflection of you
or your physician, but eitherway.
But now you'll go back to yourphysician and say, hmm,
Exactly who says who is no forCRP?
measured, that is a whole crowd.
Okay.
Dr. Michael Koren (11:18):
Well, there's still people that haven't
raised their hands, so that mustbe excuse me, I'm still eating
my lunch, okay, all right.
So, Trevor, just kind of walkthrough.
Even though we can't reliablyget hsCRP levels down, there are
some things that kind of moveit in the right direction.
Dr. Trevor Greene (11:38):
These are the favorites.
These are the five favorites.
Weight loss I discoveredsomething very interesting a
couple of nights ago.
I'm not sure what it waslistening to, but I come to
found out that the 74% there's apretty impressive number 74% of
the American population isobese.
Dr. Michael Koren (12:01):
That was the Super Bowl commercial.
Dr. Trevor Greene (12:02):
Ah, that's correct.
Him and hers.
Yeah, yeah, that's right.
Yeah, that's right.
Dr. Michael Koren (12:06):
It might be a slight exaggeration,
but I was.
I was impressed by that.
Yeah, I would say whoa.
is that true?
Now I happen to know that inthe in the in the third world,
particularly countries, forexample, where I'm from,
Barbados, where diabetes is veryrampant, obesity is a big issue
, and in a place like Barbadosyou can have 80% of the
(12:30):
population who are obese.
But what do we mean by obeseBMI body mass index?
You have to have some kind of areference BMI which is worked
out on the basis of your heightand your weight is above 25,
then you are mildly obese, up to30, moderately obese and
(12:52):
greater than 30, we're talkingabout morbidly obese.
So that's a, that's a.
That's a flag.
Getting and staying at 25 is noteasy because of our diet.
So that leads me into diet.
What is a good diet?
Now, if you break again to theinternet and social media, where
(13:13):
we all are, there's a varietyof things that you can do there
paleo, keto, I mean.
You could spend a wholelifetime trying to figure out
what the best diet is, andthere's a lot of research and
there's a lot of myths and a lotof fantasies out there.
But the two things that youhave to pay attention to in your
diet is carbohydrates, whichwould be sugar, and salt.
(13:36):
So I usually submit to mypatients the ones who I get
around with a lot, and I getaround with a lot of my patients
and I say to them if you wantto live to be as old as
Methuselah, the diet that youshould have is one that has no
salt and no sugar.
And they say what do I do about taste?
Dr. Trevor Greene (14:01):
I still have a practice, so they do come back
to me.
I say it lovingly, but thetruth is the.
The bedrock of diet really isto cut back as much as you
possibly can on your freecarbohydrate intake.
Low calorie intake is probablythe best way to start.
(14:22):
I happen to like theMediterranean diet because it
gives you a better taste.
There's a lot about it that isgood, and so that is something
that you should discuss withyour, with your physician.
Exercising, the one of thebeautiful things I I once heard
about aspirin.
(14:42):
Aspirin is good and I and I Imight have stole this from you,
Michael, okay.
Well, um, in terms ofexercising the, the when you
take your blood pressuremedicines or you take your
cholesterol medicines, or youtake your rheumatoid medicines,
(15:02):
one of the best ways to get thatmedicine to work, to get your
blood pressure down, to get yourglucose down, one of the best
ways to get it to work is totake that medicine for a
five-day walk and then take it.
Exercise Now.
Exercise should be somethingthat you enjoy.
(15:23):
If you're like me and your wifeis beating up on you at seven
o'clock at night because you'renot going to the gym with her.
That is not the kind ofexercise that you want.
Dr. Michael Koren (15:32):
That's what you're saying publicly is the
reason she's beating on you.
Dr. Trevor Greene (15:36):
Publicly Exercise, but you've got to
enjoy the exercise.
If you can find that form ofexercise that you enjoy, you're
going to accrue a much betterbenefit from it than if you're
doing it as another chore of theday, and the exercise does not
have to be really vigorous, andyou don't want to look like
(15:56):
Arnold Schwarzenegger.
What you want to do issomething that will give you
good repetition.
It is part of your philosophyof what a good day is, and you
do it on a regular basis.
The unfortunate thing aboutexercise is that you can't store
it, so it doesn't matter howmuch you do today, it doesn't
(16:17):
come for tomorrow.
That's the sad part of it all,but you don't have to be brutal
about it either.
It has to be repetitious andcontinuous and something that
you enjoy, and smoking is ano-brainer.
Smoking increases inflammationin the body in a very big way
and, interestingly enough, thenext thing that we're dealing
(16:41):
with, particularly in the youngpopulation most of you guys are
here would have grandchildrenand great-grandchildren that
generation.
You call them all sorts ofnames Zs and Ys and Ks and
whatever else but their biggestproblem is not cigarettes.
Like you knew when you weregrowing up, their biggest
problem now for smoking isactually vaping.
(17:02):
Vaping is a big problem becauseit is a highly sophisticated
way of getting nicotine in thesystem.
It's very addictive.
So if your grandkids come andthey say to you, oh, but
grandmommy and granddad, I don'tsmoke, I'm into vaping, and you
, oh, my God, you got rid of thetar, yes, but the inflammatory
(17:33):
consequences of smoking andvaping is still there and with
all the vaping tastes that areout there, it becomes very
addictive.
Aspirin Aspirin has gone fromone end of the spectrum to the
other and, like I said, the bestthing you can do with aspirin
is to take it for a five-milewalk and it will work even
better.
As we get older.
We've got to be very carefulwith aspirin and bleeding
(17:55):
aspirin and bruising.
It's tough.
But low-dose aspirin, we doknow, is beneficial and that's
something that you shoulddiscuss with your physician to
the extent that you might betaking other medicines as well.
So there's no real one hardcorestatement on aspirin, but
low-dose aspirin is also verygood.
Dr. Michael Koren (18:15):
Yeah, all excellent points.
I would just add a couple ofquick things on aspirin.
What we learned over time is ifyou can get to 70 years old and
have absolutely no evidence ofatherosclerosis, aspirin doesn't
help anymore because you'rejust not at high risk.
But that means you have nocoronary calcium, you really
(18:35):
have no atherosclerosis.
But if you're in that moderaterisk category, even if you
haven't had a heart attack,aspirin helps.
And of course, if you had aheart attack, then you should
definitely be on something likeaspirin or another type of blood
thinner, and I loved yourconcept of taking a pill for a
five-minute walk.
Let's go for 10 minutes, how's?
Dr. Trevor Greene (18:53):
that 10 minutes, there you go.
Dr. Michael Koren (18:57):
And getting results from exercise is all
about doing something you likeand getting it in your schedule.
It really comes down to that,all right.
So I think we covered all thisreally well and there's just
some numbers for everybody tosee that all these things have
been scientifically validated.
So, if you exercise more thanonce a week, how much exercise
(19:18):
do you recommend to yourpatients as a target?
Dr. Trevor Greene (19:22):
Well, the number that I have to deal with
personally, because my wifethrows this number, at me is
that we should get at least10,000 steps a day.
10,000 steps a day is hard, it'shard.
I'm up and about doing my stuffin the lab and running around.
I seldom use the elevator, Irun the stairs, things like that
(19:44):
.
I don't try to park too closeto the establishment.
You park in the parking lot andwalk.
You can get in your steps inthat kind of a nebulous way.
And uh, there was a recent Isaw a recent study that showed
that 7 000 is about optimal,primarily because 10 000 is just
(20:05):
too much.
And if you, if you ask someperson to do 10 000, after a
while they get so dejected thatthey can't get there that they
just give it up, whereas if yousay, you know what, let's go for
seven, and if you get the five,that's still better than zero.
Dr. Michael Koren (20:23):
So exercise that's the number and steps is
one element of exercise.
Obviously, there are differentways of exercising, so if you're
swimming, that's not stepsnecessarily, or?
you're biking.
I like to tell my patients totry to do two hours of aerobic
exercise per week and try tomake those sessions at least 20
(20:44):
minutes long.
So personally, I'm pretty goodat doing at least 30 minutes
four days a week, and I like togo to the gym, ride the bike and
that's what works for me.
But finding the thing that youlike to do is so important, and
it could be collecting seashellson the beach, it could be
working in the garden, and aslong as you're sort of moving
(21:06):
around getting up and down, thatwould count.
It doesn't really matter whatyou do, but doing it for two
hours a week, 30-minute sessions, to me is really what you
should be targeting, and I thinkit's pretty clear that if
you're smoking now, please workwith your physician to get off
of it, all right.
So you want to jump into this alittle bit in terms of exactly
(21:30):
the mechanism by which CRP leadsto cardiac problems exactly the
mechanism by which CRP leads tocardiac problems.
Dr. Trevor Greene (21:37):
Yeah, we don't want to bog you down with
too much clinical detail, butcertainly the inflammation
causes the reactions in yourbody that will promote
inflammation, and they're very,very complex pathways in the
body and we go after all of themin our different ways of coming
(21:58):
at it.
The big thing really would becoagulation and clotting.
Clotting is a big issue,particularly if there is anyone
in the room who might besuffering from atrial
fibrillation and your physicianputs you on your blood thinners.
That's where that plays intothis whole complex, but it's
very sophisticated.
The main thing really would beto make sure that you get your
(22:24):
hsCRP high-sensitivity CRP andgo from there work with your
physician.
Dr. Michael Koren (22:31):
Yeah, and this is an area of confusion for
some people.
So hsCRP was actually firstdiscovered because it's
expressed in extremely highlevels when people come in with
pneumonia, particularlypneumococcal pneumonia, and it's
thought that this is part ofthe body's mechanism to identify
(22:51):
a foreign invader and to helpthe immune system attack it.
And we are probably built tohave this response because of
prehistoric days when we didn'thave modern medicine and this is
all we had.
But if you had to compare hsCRPto penicillin in terms of
fighting bacteria, you're goingto choose penicillin and, of
(23:14):
course, hsCRP, Although it mayhave some beneficial effects
with regard to responding toinfections in modern times, it's
probably a net negative because, as Dr.
Greene mentioned, it leads toblood clots, it leads to what we
call inflammatory cytokines,which are these chemicals that
(23:35):
get the immune system all hotand heavy, and then there's
something called the complementpathway that gets your
antibodies all fired up.
So by getting your immunesystem fired up is not
necessarily good for your heartand blood vessels
Dr. Trevor Greene (23:48):
Or like a good thing going bad.
Dr. Michael Koren (23:49):
Exactly and again this also summarizes it
that short-term that there couldbe some benefit for infection
or injury, but long-term there'smuch more harm and frankly, in
modern society.
The long-term issues kill many,many more people than the
short-term issues, and we havelots of good ways for dealing
(24:11):
with short-term infections.
So we don't necessarily needthis system to kick in, and
these are just a little bit moresophisticated slides, but it
just tells you all the differentways.
I'll turn this way.
These are all the differentcells in the body that are
responsible for inflammatoryreactions and the cytokines are
(24:34):
the chemicals that amplify thatresponse.
And the reason we're bringingthis up is because a lot of the
research that we're doing now isspecifically targeting
cytokines, Not so much the CRP,which is sort of the end result
of the inflammatory cascade orthe immediate reaction, as the
case may be, but getting veryspecific, because there are now
(24:58):
dozens of cytokines that havebeen identified and we think by
blocking specific cytokines thatare important in terms of
cardiac and vascularinflammation, we can come up
with that magic bullet that doeswhat it needs to do for the
heart and blood vessels withoutbothering the immune system when
(25:19):
it comes to other things.
So we're particularly excitedabout this whole concept.
I don't know if you have anycomments about that.
And there's our pictureclose-up.
Good job to our presentationstaff for getting such a
beautiful picture.
I appreciate that.
Dr. Trevor Greene (25:36):
I think it helps me understand it at least.
Dr. Michael Koren (25:41):
All right back to audience questions.
So which of these cytokines iscurrently under investigation
for its potential to reducevascular inflammation?
If anybody gets this right,I'll be impressed.
Vascular information Now.
If anybody gets this right,I'll be impressed.
So interleukin 1, I should meaninterleukin 6,.
(26:08):
Tnf-alpha or interleukin 10.
Show of hands who thinks it's 1?
Okay.
Who's going to raise their handfor this question?
Who thinks it's 2?
We get 1, okay.
And who thinks it's three, okay, interesting.
Well, there are TNF-alpha drugson the market, but that's a
cytokine, that's more forgeneral inflammation, for
example rheumatoid arthritis.
(26:28):
We have TNF-alpha drugs forinflammatory bowel disease, for
example Crohn's disease.
Interleukin-10 is interesting,but the actual answer is
interleukin-6.
And, as I mentioned, I wouldhave been surprised if anybody
got that.
We've looked at other of thesecytokines over the years and
we're really, really excitedabout this particular one
(26:49):
because we think this is themost specific trigger for
vascular inflammation and as wespeak, we're doing studies
looking specifically at blockinginterleukin-6 and seeing
whether or not people do betterfrom a heart disease standpoint.
So you want to give a littleLp(a)?
Dr. Trevor Greene (27:07):
Yeah well.
Lp(a) lipoprotein AnyAfrican-Americans in the crowd?
Yeah, definitely Be a.
I feel like high levels oflipoprotein kind of plague the
African-American population,primarily because of genetics.
The only way you can fix thatis if you change your parents,
and that would be a littletricky.
(27:27):
So once you're stuck with that,we know that.
One in five people around theworld.
Dr. Michael Koren (27:31):
My kids have been trying that.
It hasn't worked
Dr. Trevor Greene (27:33):
It hasn't quite worked.
So that is another marker thatyour physician can use to look
to see if you're particularlyhaving trouble getting your
lipid levels as we call them asa general group under control.
Dr. Michael Koren (27:52):
Yeah, we're particularly interested in this
because we have a number ofmolecules in clinical research
that actually lowerlipoprotein(a) up to 95%, and
lipoprotein(a) is responsiblefor vascular inflammation.
So it's one of the factors thatincreases your hsCRP and, as Dr.
Greene mentioned, it's veryhighly concentrated in certain
(28:13):
families.
So if you have a risk of heartdisease in your family, so if
you have a risk of heart diseasein your family say, a mother, a
father or brother or sister oran uncle or aunt who died before
age 65 of cardiovasculardisease or had a heart attack or
stroke before 60 you shouldknow your Lp(a) and we're happy
to do that for free at theresearch office and,
(28:34):
interestingly, most people haveLp(a)s that are what we call
normal, which would be below 50milligrams per deciliter, but we
see some people with thisfamily history that can have
Lp(a) levels of 500, just hugeelevations.
So that's something you shouldknow and this connection between
Lp(a) and hsCRP is somethingthat we're studying now and we
do have some really, reallyinteresting clinical trials to
(28:57):
lower lipoprotein( a) if we findthat you have high levels.
Dr. Trevor Greene (29:00):
So you've just became a very, very
well-educated audience.
So when you speak to yourprimary care physician or your
cardiologist and you mentionLp(a), you might very well hear
what are you talking about.
What is that?
And you'll be able to say ohwell, I know about that stuff, I
heard all about it, so it'sgood stuff.
Dr. Michael Koren (29:20):
Yeah, three years ago, when we started
teaching people about LP(a) andhsCRP, most of the physicians
really didn't even know what itwas, and more and more doctors
are now learning it and we'refinding more and more doctors
very open to this message, butit's still not a standard in
practice, although a lot of usagree that it should be
Dr. Trevor Greene (29:41):
and that's the beauty of having stuff like
this, where we bring thatinformation directly to you, so
to speak, so that we can kind ofexpand it more, because,
depending on your relationshipwith your physician, you might
actually get to spend that extraminute or two thinking about
ways of trying to control thatcholesterol that you just simply
(30:01):
can't get control, or thestatins might not be working the
best, and then you're runningfrom one statin to the next.
Are you going on to the new?
You say, could we take a lookat our Lp(a)?
You know my old uncle Right?
Dr. Michael Koren (30:15):
right, right, exactly.
Dr. Trevor Greene (30:17):
That's the kind of sense that we want to
pass on.
Dr. Michael Koren (30:20):
Yeah, and here's a little pearl that,
again, a lot of physicians donot know.
So when you go to Quest orLabCorp one of these places and
you get your LDL measured, it'smeasured indirectly.
It's not actually being measureddirectly, and within that
measurement is actually Lp(a),because Lp(a) is a form of LDL
cholesterol.
So you might have a slightlyelevated level of LDL and you
(30:44):
may not think that much about it, but if that LDL slight
elevation is due to Lp(a),that's a big threat.
It's a really big threat, andso doctors don't always
understand that directmeasurement of LDL doesn't show
lipoprotein(a), but most peoplewho get their LDL measured are
lumping all the forms of.
LDL in the same measurement andnot breaking it down.
(31:06):
And you don't even know howmuch of that is Lp(a).
Dr. Trevor Greene (31:10):
Which brings up the golden code; you see what
you look for.
You recognize what you know.
Right, there you go, exactly.
If you're not looking for it,then it's there.
You're not going to see it,
Dr. Michael Koren (31:20):
right and we call it the triple threat,
because it's pro-atherogenic,meaning it causes plaques, it's
pro-thrombotic, which means itcauses clots, and it's
pro-inflammatory, which createsirritation and other problems
within your blood vessels.
And, as mentioned, Lp(a) testsare inexpensive.
(31:42):
They can be ordered by anyphysician and more and more
doctors are adding it as part oftheir standard lipid panel, but
it usually is not in the panelunless the doctor asks for it
specifically.
Right, and anybody here in theaudience just let us know and
we'll do it for you for free.
So we'll do it at the researchoffice, we'll set a time for you
(32:03):
to come over and it's simpleand you'll know what you're
dealing with.
And so we're going to kind ofend with talking a little bit
about clinical trials and thesedata just absolutely fascinate
me, Trevor, is when you go topeople in either US or Europe
who have never been exposed to aclinical trial just general,
(32:25):
normal people in the populationand you say, do you have any
interest in participating in aclinical trial?
Just ask that question.
Surveys have shown between 31%and 50%.
On average, about 38% to 40%say they have interest.
In Europe it's actually alittle less than the US.
For whatever reasons it is.
Yeah, interestingly.
(32:46):
But if you go to somebody that'sdone a clinical trial before
and you say, will youparticipate in a second clinical
trial, over 97% say yes.
In our centers here inJacksonville it's 99%.
So how many things in life canyou say that there's a lot of
skepticism the first time youtry it, but once you've been
(33:07):
exposed to it you become a bigbeliever and supporter of it.
Not too many things, not verymany things.
Yeah, and so I find thisfascinating and it's also why we
want to get the message out, tohelp people at least have some
experience with this, becauseit's also why we want to get the
message out to help people atleast have some experience with
this, because it's a verynurturing process and people
(33:27):
learn a lot from being in aclinical trial and I believe
that there's a lot of valuethat's derived in multiple
different ways.
All right, so then we have ourMedEvidence! platform.
I think we had a couple ofpeople that raised their hands
looking at it and again, it'skind of like Trevor and I just
talking about it.
We have now online lots ofdiscussions with people about
the issues of the day and youcan decide what you want to
(33:50):
glean from it, but there'salways going to be insights.
So a couple of the MedEvidence!podcasts that we've done
recently I encourage you to lookat is one with Jerome Adams.
I don't know if you recognizethis, but Jerome Adams was
actually the Surgeon Generalduring the first Trump
administration, so he workedclosely with Mike Pence and he
was part of the first Trumpadministration and he and I had
(34:13):
a wonderful podcast together,wonderful podcast together
Recently.
This is kind of interesting,just the timing of it is that
the last public interview thatTony Fauci did before he got his
get out of jail free card fromJoe Biden was with me in
MedEvidence! so it was just acoincidence.
But Tony and I had a niceconversation about his career,
(34:37):
which is really a spectacularcareer.
It's just mind-boggling howmany things he did during the
course of his career.
That kind of got lost in allthe politics.
But if you want to find outwhat his opinion is about where
COVID-19 came from or did hemake any mistakes or things he
would do differently, check outthe podcast and we say hero or
(34:57):
villain.
I find this so fascinating,Trevor, when I tell people check
out the podcast, they alreadyhave these ingrained opinions
about Tony.
Fauci mostly based on politicsand have never really heard him
speak as a physician.
Check it out.
I'd be curious to see what yourreaction is.
Dr. Trevor Greene (35:17):
The quote that goes there, and you notice
I'm giving you these littlequotes: Perception sometimes is
more powerful than truth,
Dr. Michael Koren (35:23):
exactly.
Yep, all right, that's spot on.
And then another one that we didthat was interesting was with a
local investigator and a goodfriend, Bharat Misra.
He's done programs here with me, he's a gastroenterologist, and
we talked about this concept ofhaving warning labels on
alcohol, and you might know thatthe surgeon general, before the
(35:44):
change in administrations,submitted to Congress a proposal
to put warning labels onalcohol because alcohol is
associated with higher risk forcertain cancers.
But in our world we thinkalcohol probably has a slight
beneficial effect for coronarydisease.
So me as a cardiologist andBharat as a gastroenterologist
had discussion about whether ornot there should be warning
(36:05):
labels on alcohol.
So people have enjoyed thatpodcast.
And then, finally, as wementioned, there are some
ongoing studies in our communitythat are looking at the concept
of inflammation, and just letanybody here know that you're
interested and we'll get youinvolved.
Or if you have a friend orfamily member who you think
might benefit, we'll get youinvolved.
(36:27):
You know so, for example,people that have had a diagnosis
of heart disease may not evenknow what their CRP is, and we
have a study that's just lookingat your numbers.
Help you look at your numbersand understand whether or not
the average person in thecommunity is elevated or not.
So very simple study be anintroduction into clinical
trials and I think you'll enjoyit.
(36:47):
And then we're doing moresophisticated studies.
As I mentioned, we're lookingspecifically at blocking IL-6.
And if you look at the podcastthat I did with Dr.
Paul Ridker, you get a lot moredetails about that particular
approach.
But that's a very sort ofcutting-edge research to see if
a new monoclonal antibody willprotect people against the
(37:07):
effects of IL-6.
And my final word before we getto questions is just sign up.
We have about 100,000 peoplenow that are part of our overall
email and podcast universe.
It's free information.
There's no obligation.
We protect your information.
We never sell your information.
So it's a nice opportunity foryou to just be exposed to people
(37:30):
that will give you objectiveinformation.
We're not trying to sell aweight loss drug.
We're not trying to sell oursupplements.
Sell a weight loss drug, we'renot trying to sell our
supplements.
We're not trying to sell ourcrazy diet book or we're not
trying to either promote or dissvaccines.
We're just trying to get to thetruth of the matter.
And so I think you'll find itinteresting and we'd encourage
(37:51):
you to sign up, and it's as easyas just taking the sheet in
front of you writing your nameand email address or phone
number, and that will get youinto the community and hopefully
get you more involved in whatwe're doing in clinical research
.
Announcer (38:02):
Thanks for joining the MedEvidence! podcast.
To learn more, head over toMedEvidence.
com or subscribe to our podcaston your favorite podcast
platform.
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