The Curbsiders Internal Medicine Podcast

Episode 518: Cardiology Meets Longevity

Release Date: March 23, 2026
Guest: Dr. Greg Katz (Cardiologist, NYU Grossman School of Medicine)

Episode Overview

This engaging episode explores the intersection of cardiology and longevity, focusing on cardiovascular risk assessment, prevention strategies, lipid management, and the nuanced use of advanced biomarkers and imaging. Hosted by Drs. Matthew Watto, Paul Nelson Williams, and Paul Wertz, the conversation features cardiologist Dr. Greg Katz, whose practical wisdom, evidence-based insights, and humanistic approach shine as they tackle everything from lipid panels to the latest on coronary calcium scoring and the realities of patient-centered care.

Key Discussion Points

1. The Human Side of Medicine and Prevention

[03:46–07:56]

• Wellbeing for Patients, Teams, and Self:

  • Dr. Katz shares advice that shapes his teaching:

    "Your job is to not just know the medicine and take care of patients. It's to elevate the experience for everybody around you..."
    — Dr. Greg Katz [06:11]

  • Emphasis on kindness to all hospital staff, positivity, and academic curiosity.

• Clinical Case Setup:

  • Art Esclerosis, a 46-year-old man with metabolic syndrome, pre-diabetes, sleep apnea, and concerning family history, seeks heart attack prevention.

• Preventive Framework:

  • Dr. Katz explains that patients like Art are "secondary prevention waiting to happen":

    "The only difference between him being primary and secondary prevention is the time when he's coming to medical attention."
    — Dr. Greg Katz [09:31]

• Patient Tailoring:

  • Gauge the patient's desire for intervention—some want every possible metric, others shy from medicalization.

    "You need to take his temperature, you need to understand where he is mentally coming from, and you need to meet that person where they are..."
    — Dr. Greg Katz [12:47]

2. Navigating Laboratory and Biomarker Interpretation

[18:18–32:34]

• Lipid Panel Basics:

  • Dr. Katz frames the lipid panel as two stories:
    • LDL or non-HDL: Atherogenic particles
    • TG/HDL ratio: Metabolic health/Insulin resistance

• Importance of Triglyceride/HDL Ratio:

  "Metabolic health is having a moment in the longevity space, but it's been part of classic medical teaching for decades..."
  — Dr. Greg Katz [18:46]

• Waist-to-Height Ratio:

  • Recommended over waist-to-hip for metabolic risk.

• Use of Advanced Lipid Markers—ApoB and Lp(a):

  • ApoB: Better reflects atherogenic particle count, especially in metabolic syndrome

    "If I'm going to use a biomarker, shouldn't you use the best biomarker?... Even if it doesn't change practice for everybody..."
    — Dr. Greg Katz [26:28]

  • Interpretation: ApoB should typically be 15-20% lower than LDL; if higher, focus management on ApoB.
  • Targets: For secondary prevention, shoot for ApoB ≈ 45–60, extrapolating from LDL targets.
  • Guidelines: Katz critiques the guideline complexity and age bias ("undertreat young, overtreat old").

3. Risk Calculators, the Limits of Prediction, and Why They Can Fail

[32:34–37:41]

• Risk Calculators (Prevent, Pooled Cohort Equations):
  • Excellent population tools, but not for individuals, particularly:
    • Young with high risk (missed/undertreated)
    • Elderly with low modifiable risk (over-medicalized)
  • Dr. Katz cautions against over-relying on calculated numbers:

    "Risk is asymmetric... cardiovascular disease is the number one killer... The side effects (of drugs) go away; a heart attack can ruin your life forever." — Dr. Greg Katz [33:44]

  • Using calculators for BP vs. Lipids is inconsistent.

4. Lipoprotein(a) [Lp(a)]—A Risk Enhancer

[37:41–43:06]

• What is Lp(a)?
  • A proatherogenic, prothrombotic LDL variant—strong genetic driver.
  • Used as a "tiebreaker" or risk enhancer for ambiguous cases.

    "High LP is going to be a tiebreaker for me of do I put this person on a GLP1 agonist... it influences the tone of my voice with my recommendations."
    — Dr. Greg Katz [41:47]

• Clinical Example: Even with "perfect" lifestyle, a high Lp(a), especially with family history, should push clinicians to recommend aggressive prevention.

5. Imaging: Coronary Artery Calcium (CAC) and CTA

[46:01–57:43]

• CAC Score:

  • Younger Patients (<50):
    • A positive CAC (>0) is a huge red flag
    • Negative/zero CAC can be falsely reassuring (may miss non-calcified plaque)
    • "I would have expected it to be zero... a 46 year old should have a calcium score of zero."
      — Dr. Greg Katz [49:29]
  • Older Patients:
    • Used for de-escalation (e.g., if statin intolerant, a low or zero score relaxes intensity).
    • Use percentile calculators (e.g., MESA) for context.

• CCTA:

  • Superior for identifying soft plaque, not widely used in "prevention" yet, mainly for symptoms.

• Decision Summary:

  • CAC best for those in middle age (mid-50s+), less helpful (except as a positive) in the very young or very old.

6. Therapeutic Strategies: Lipid Lowering Beyond Statins

[58:23–66:30]

• Medication Ladder:

  • First Line: Statins (preferring rosuvastatin or atorvastatin)
  • Next: Switch statin or add ezetimibe; consider pitavastatin for myalgia.
  • If needed: PCSK9 inhibitors (insurance coverage improving), bempedoic acid (last line, limited potency and side effects).

• Addressing Side Effects:

  • Trust patient reports; many options to adjust therapy.
  • No cognitive risk at very low LDL levels; vascular events are a greater dementia concern.

    "Vascular dementia is a very real cause... I'm so much more worried about you developing vascular dementia than I am about...statin-induced dementia."
    — Dr. Greg Katz [64:23]

• Statins and Diabetes Risk:

  • Minimal A1C impact ("If you get diabetes from a statin, you are a Snickers bar away from getting diabetes anyway." — Dr. Katz [65:28])

7. Aggressive Primary Prevention: High-Risk Phenotypes

[66:37–72:36]

• Case: Young fit woman (Ms. Lola Lipa) with strong FHx, normal lipids, but very high Lp(a):
  • Family history and high Lp(a) override "normal" appearing labs and stellar lifestyle.

    "This is a patient who is coming to medical attention... at a very, very scary family history and lab data..."
    — Dr. Greg Katz [67:40]

  • Target LDL/APOB much lower than guidelines.
  • Consider aspirin for primary prevention if no contraindications.
  • In reluctant patients, CCTA might be used to demonstrate soft plaque, informing aggressive management.

8. Insulin Resistance, Diets, and Biomarker Value

[73:01–88:12]

• Case: 'Biohacker' on Carnivore/Keto:

  • High ApoB, high triglycerides, low HDL, “normal” A1C—“lean mass hyper-responder” phenomenon.
  • Dr. Katz discusses value of fasting insulin, but favors TG/HDL ratio for practical assessment, with the caveat of ethnic variability.

• Diet, Lipids, and the Accelerated Atherosclerosis on Keto:

  • Referencing the "Keto-CTA" study:

    "The rate of progression of cardiovascular disease...was basically as fast as any cohort... that's ever been studied in terms of progression of subclinical atherosclerosis."
    — Dr. Greg Katz [81:27]

  • Mechanism may be unclear, but the outcome data guides concern—not mechanistic speculation.
  • Sustained high LDL from diet does appear to accelerate atherosclerosis, even in a year.

• Patient Relationship:

  • Importance of aligning with patient goals, transparency, and collaborative decision making.

    "We are on the same side, we both want the same thing, which is for you to feel good and for nothing bad to happen."
    — Dr. Greg Katz [84:24]

Notable Quotes & Memorable Moments

• "If you don't pay attention to who the humans are, like ChatGPT will be 100% a better doctor than you."
  — Dr. Greg Katz [13:42]

• "Meet patients where they are and understand who the human is, not just what the risk calculator tells you."
  — Dr. Greg Katz [89:10]

• "[Cardiovascular] disease is largely preventable; risk calculators miss young patients who are at elevated risk."
  — Dr. Greg Katz [89:10]

• "You don't get extra points at the pearly gates for having an A1C at 0.1 percentage points lower."
  — Dr. Greg Katz [66:26]

• Host banter about creative patient names and podcast pets provides levity throughout (e.g., “Art Esclerosis,” “Lola Lipa,” and cat interruptions).

Timestamps for Important Segments

• Expert Introduction & Philosophy: [03:20–07:26]
• Risk Factor Approach & Primary Prevention: [08:07–13:42]
• Lipid Panel—Traditional and Advanced Markers: [18:18–32:34]
• Risk Calculators Discussion: [32:34–37:41]
• Lipoprotein(a) as a Risk Enhancer: [37:41–43:06]
• Coronary Calcium Scoring (CAC): [46:01–57:43]
• Medication Sequencing for Lipid Control: [58:23–66:30]
• High-Risk Young Patient—Genetics and Management: [66:37–72:36]
• Lifestyle, Insulin Resistance, “Hyper-Responders:” [73:01–88:12]
• Dr. Katz’s Take-Home Points: [89:10]

Key Takeaways

1. Cardiovascular prevention must be personalized and relationship-driven:

   • Numbers and risk calculators offer guidance, but meaningful prevention requires individualized understanding, especially for young, high-risk, or genetically predisposed patients.

2. Advanced lipid markers (ApoB, Lp(a)) add actionable nuance:

   • ApoB outperforms LDL in many situations; Lp(a) is a critical risk enhancer, particularly with family history.

3. CAC scoring is a “double-edged sword”:

   • Highly useful in middle age, but limited value or misleading when negative in the young.

4. Dietary extremes that drastically elevate lipids (high saturated fat/ketogenic/carnivore) likely accelerate atherosclerosis, and this risk is not reliably mitigated by other healthy metrics.

5. The art (and fulfillment) of medicine is found in celebrating patient victories, supporting lifestyle change, and helping each person truly understand and own their risk and prevention plan.

Resources Mentioned

• Dr. Greg Katz’s Substack Newsletter: gregkatzmd.substack.com
• Core IM Podcast—Beyond Journal Club
• MESA CAC Percentile Calculator (for interpreting calcium scores)
• Keto-CTA Study (lean mass hyper-responder atherogenesis)

For further learning and practical clinical pearls, check out Dr. Greg Katz’s writing, the Core IM Podcast, and explore the evidence-rich show notes on the Curbsiders website.