Podcast Summary: Healthier World with Quest Diagnostics

Episode: The Cardiometabolic Approach: A Solution to Modern Disease Risk Assessment

Date: February 17, 2025
Duration: 20 minutes
Host: Dr. Mason Latsko
Guest: Dr. Mark Penn, Founder and CMO, Cleveland Heart Lab at Quest; Director of Research, Summa Cardiovascular Institute

Episode Overview

This episode explores the cardiometabolic approach as a progressive strategy for assessing and mitigating the risk of chronic diseases. Dr. Penn details why moving beyond treating diseases in isolation is essential, highlighting the need for integrated assessment across cardiovascular, metabolic, liver, kidney, and endocrine health. The discussion centers on prevention, holistic risk evaluation, actionable laboratory testing, and the critical role of primary care in early intervention.

Key Discussion Points & Insights

The Need for a Cardiometabolic Approach

• Changing Landscape of Risk Factors
  Smoking rates and LDL-cholesterol levels have decreased, yet heart attacks and strokes are rising.

  • "'We now exist in a time where we have the lowest smoking rate in the history of our country. Yet since 2010, the risk of heart attack and stroke are actually increasing. So how could that be?'" (01:18 — Dr. Penn)
  • Shift from high fat to high sugar diets has driven multifactorial risk: "We've become heavier, we've become sweeter, higher sugars. And those risk factors are now driving heart disease, even though our LDLs are far lower than they were in the 90s and even though we're smoking far less…" (01:54)

• Desiloed Thinking
  Chronic diseases share interconnected risk profiles.

  • "It's not thinking about the kidney, thinking about the liver, thinking about the heart at different times. It's thinking about the disease profile that drives a commonality of the diseases across the organs." (02:42)

Prevention and Early Identification

• Pre-disease Conditions & Actionable Testing
  • Many patients live with conditions for years before overt disease appears.
  • Early identification allows for effective intervention:
    "'If we use cardiometabolic testing to define who has a condition, the reality is the likelihood of diet and exercise to reverse that condition so they never develop a disease is very possible.'" (03:50)
  • Hemoglobin A1C can miss risk—insulin resistance testing adds nuance.
    • Example: Young adults with "normal" A1C may still harbor substantial cardiometabolic risk and can avoid progression through lifestyle change. (04:26)
    • "The insulin resistance score turns out to be incredibly powerful because we can identify who amongst those normal range of A1Cs actually is at higher risk." (04:48)

Role of Endocrine Disorders

• Interrelationship with Cardiometabolic Disease

  • Some endocrine disorders—hypothyroidism, hyperaldosteronism, low testosterone in men, PCOS in women—directly increase cardiometabolic risk.
    • "We need to think about how obesity and cardiometabolic disease worsen our endocrine system. But we also have to recognize how our endocrine system contributes to cardiometabolic disease. It's definitely a two way street." (07:34)

• Examples:

  • Hypothyroidism → weight gain and worsened cardiometabolic status
  • Hyperaldosteronism → resistant hypertension
  • Low testosterone or PCOS → increased metabolic and cardiac risk

Holistic Assessment & Management Strategies

• Comprehensive Risk Assessment

  • Go beyond symptom- or organ-based evaluation.
  • Evaluate for: inflammation, blood sugar/insulin resistance, and endocrine factors.

• Liver Assessment

  • Fatty liver is prevalent and reversible with weight loss (lose 10% of body mass).
    • "The best way to actually decrease fatty liver is to lose weight… GLP-1s… actually reverse fatty liver disease." (09:12)
  • Utilize AST/ALT, Fib-4, and ELF tests for staging and determining need for referral.
    • "If you have an elevated ELF high risk… you'd need to send somebody to a hepatologist." (11:11)
  • Do not stop statins reflexively when LFTs rise—investigate for metabolic liver disease.

• Kidney Assessment

  • Importance of urine albumin/creatinine ratio: stage 1 CKD can exist with normal GFR but elevated proteinuria—often overlooked.
    • "You cannot diagnose CKD stage 1 without checking for protein in the urine. But far too often we're comforted by the fact that the GFR is normal and we don't look any further." (11:56)
  • Reiterate the need for monitoring, aggressive treatment, and nephrology referral for persistent/progressive proteinuria.

• Cardiac Assessment

  • Evaluate lipids for both concentration and particle number (apoB); high particle number is pro-atherogenic even with controlled LDL.
    • "If the apob is elevated but the LDL is controlled, that implies there's a little bit of LDL, but a whole lot of LDL particles. Those are small, dense LDL particles… proinflammatory and pro-atherogenic." (12:56)
  • Aim for lower LDLs in high-risk groups; use inflammation (MPO, Lp-PLA2, hs-CRP) for nuanced risk stratification.

Laboratory Empowerment for Primary Care

• New laboratory testing empowers both patient education and enables primary care providers to identify risk earlier.
  • "The testing allows primary care, family medicine, internal medicine physicians to manage the patients on their own, to get the feedback they need and to recognize when in the patient's journey they should be referred to a specialist." (14:07)
  • Clear thresholds for specialist referral:
    • Hepatologist for high ELF liver fibrosis
    • Nephrologist for persistent CKD progression
    • Lipidologist for difficult hyperlipidemia

Key Takeaways & Final Perspective

• Outdated Guidelines vs. Modern Disease

  • Traditional guidelines don’t reflect real-world metabolic risk ("If you're going to live and die by the guidelines, you're practicing old medicine." – 16:13)
  • Cardiometabolic risks and population diabetes rates are far higher than in landmark cholesterol trials.

• Proactive Risk Assessment is Crucial

  • Modern heart, kidney, liver, and even dementia risks stem from interconnected metabolic drivers.
  • "Unless we're going to get more proactive in assessing risk… we're still going to have 45% of people die at home with their first heart attack. It's just not going to change." (16:53)
  • The earlier risk is defined, the more likely disease can be prevented.

• Empowering Primary Care

  • "Primary care physicians are the ones who determine how many heart attacks their patients have. Cardiologists stop them… the drivers of the disease are exactly what you're seeing every day when the patients walk through the door." (18:14)
  • Use reproductive and sexual health history (erectile dysfunction, gestational DM or HTN) to identify elevated risk.
  • "The disease is cardiometabolic disease. And we need to turn that around as early as we can because all those other organs will get better or be prevented from ever having disease if we do that." (19:40)

Standout Quotes & Moments

• “We’ve become heavier, we’ve become sweeter, higher sugars. And those risk factors are now driving heart disease, even though our LDLs are far lower than they were in the 90s and even though we’re smoking far less…” (01:54 – Dr. Penn)
• “It’s not thinking about the kidney, thinking about the liver, thinking about the heart at different times. It’s thinking about the disease profile that drives a commonality of the diseases across the organs.” (02:42 – Dr. Penn)
• "If we use cardiometabolic testing to define who has a condition, the reality is the likelihood of diet and exercise to reverse that condition so they never develop a disease is very possible." (03:50 – Dr. Penn)
• "It's definitely a two way street." [on endocrine and metabolic disease] (07:34 – Dr. Penn)
• “Primary care physicians are the ones who determine how many heart attacks their patients have. Cardiologists stop them.” (18:14 – Dr. Penn)
• “We got to stop thinking about heart attack, stroke, renal failure, and liver transplant as the disease. The disease is cardiometabolic disease.” (19:40 – Dr. Penn)

Timestamps for Key Segments

• 00:00 – 01:13 | Introduction & setting context
• 01:13 – 03:20 | Dr. Penn on the evolution of risk factors & need for integrative approach
• 03:20 – 06:05 | Prevention, pre-disease states, and value of early tests
• 06:05 – 08:00 | Role of endocrine disorders in cardiometabolic disease
• 08:00 – 13:43 | Organ-specific holistic assessment: liver, renal, cardiac focus
• 13:43 – 15:35 | Laboratory empowerment and primary care as frontline
• 15:35 – 19:53 | Takeaways: limitations of guidelines, proactive risk, empowering primary care
• 19:53 – End | Closing remarks and appreciation

Summary & Takeaways

• Cardiometabolic approach = holistic, proactive, individualized risk assessment across interrelated conditions.
• Laboratory advancements arm both patients and primary care with the ability to identify risk early—before disease manifests.
• Prevention, lifestyle change, and early intervention—guided by modern lab testing—are the most potent strategies to reduce the burden of chronic illness.
• Primary care providers are the linchpin in risk identification and intervention, with clear guidance and referral criteria based on nuanced lab data.
• Call to Shift Thinking: The true disease to target is “cardiometabolic disease”—acting early can simultaneously reduce cardiovascular, liver, kidney, endocrine, and cognitive decline.