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The Dr. Gabrielle Lyon Show
How to Prevent Heart Disease with Mitochondria, Muscle, and the Endothelial Glycocalyx | Dr. Michael Twyman
01:43:10
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- [00:00]
Dr. Gabrielle Laing
Most people think heart disease starts with a bad cholesterol number. But the truth, the damage often starts decades earlier, before you feel it, before you see it, and before your doctor catches it. And once that early damage begins, it's silent. But it's not inevitable. You just need to know where to look and what to do next. Most cardiologists don't talk about nitric oxide. They don't measure VO2 max. They don't ask about grip strength or muscle mass. But they should, because muscle is one of the most powerful protectors of your heart and mitochondrial health that might be the key to your entire cardiovascular future. In today's episode, you'll learn why standard cholesterol labs are incomplete, how the loss of skeletal muscle speeds up heart disease, what biomarkers matter more than ldl, and why diagnostics, not guesswork, are the future of prevention. This is the medicine of what's possible. And my guest today is one of the few cardiologists practicing it. Dr. Michael Twyman, expert in mitochondrial optimization, arterial imaging, and and a bio individual muscle centric prevention approach.
- [01:30]
Matt
So if you could prevent a heart.
- [01:32]
Dr. Gabrielle Laing
Attack before it starts, wouldn't you want to know how? Let's talk about what it really takes to become heart attack proof with Dr. Michael Twyman. Dr. Mike Twyman, welcome to the show.
- [01:49]
Dr. Michael Twyman
Thank you for having me back. Hello.
- [01:51]
Dr. Gabrielle Laing
Has it been 40 seconds yet?
- [01:54]
Dr. Michael Twyman
Not yet.
- [01:55]
Dr. Gabrielle Laing
Okay. Well, as soon as it reaches 40 seconds, someone in the US had a heart attack, and every 33 seconds, someone dies of cardiovascular disease.
- [02:06]
Dr. Michael Twyman
It's a horrible stat.
- [02:08]
Dr. Gabrielle Laing
You know, it makes me think, how have we not gotten better at treating that?
- [02:15]
Dr. Michael Twyman
I think we're getting there, but it's still the number one killer. We did this episode three years ago. Stats haven't changed that much since then. And I think we're going to dive into a lot of the topics today that I think might be beneficial to really help people become more heart attack proof.
- [02:31]
Dr. Gabrielle Laing
Can someone actually die of a broken heart?
- [02:33]
Dr. Michael Twyman
Absolutely. It's known as takotsubo syndrome or broken heart syndrome. Takotsubu is a Japanese kind of fishing vessel, I should say fishing pot that they catch octopus in. And that's what the left ventricle looks like when people have this broken heart syndrome. So they present after an emotional event. Somebody in the family dies. They're in a car accident, they smoke cocaine. Something happens where their sympathetic drive is very high, and they present to the hospital, like if they're having a heart attack. And we would rush them off to the Cath lab find out that they didn't have any significant blockages in the arteries. And then when we did the left ventricular gram, their heart wasn't pumping very well. And so kind of supportive care. After a couple days, usually the heart function returns to normal, but it's a high risk of sudden cardiac death.
- [03:16]
Dr. Gabrielle Laing
When you have that, is it mostly women or men?
- [03:20]
Dr. Michael Twyman
Generally women. Older women particularly.
- [03:23]
Dr. Gabrielle Laing
We hear the term heart disease all the time. But what is heart disease?
- [03:29]
Dr. Michael Twyman
That's the umbrella term. I mean, there's coronary artery disease, there's heart failure, there's valvular heart disease, so you really had to do define terms. But vascular disease, 60,000 miles of blood vessels, you got to go looking where the disease is at.
- [03:46]
Dr. Gabrielle Laing
You know, as I was preparing for this episode, cardiovascular disease, as you had mentioned, is still so prevalent, and it's not getting better, which is surprising. And it makes me think, okay, what do we know that drives heart disease? And again, it is an umbrella term. So perhaps we start with, I don't know. Take your pick. Stroke.
- [04:14]
Dr. Michael Twyman
So stroke can be either ischemic or thromboembolic. So ischemic means there's not blood flow coming to the tissue, and without oxygen nutrients coming to the tissue, that tissue starts to die. An embolic event is where more of a blood clot forms. Many times in heart patients, it's due to atrial fibrillation. A clot forms in their left atria. That clot breaks free, gets lodged in the brain, and steals blood flow from the territory downstream. And that tissue will die unless it's revascularized. So stroke, honestly, it's probably more scary to many people because heart attacks. If you survive to get to the cath lab, you usually do pretty well. But a stroke can be debilitating for the rest of your life. But the same risk factors for heart disease are the same things that contribute to stroke in most people.
- [04:53]
Dr. Gabrielle Laing
And what are those things?
- [04:55]
Dr. Michael Twyman
I mean, it's the common ones. It's smoking, it's high blood pressure, it's diabetes, high lipids, physical inactivity. Those are probably the top five. But there may be 395 other things that can really damage your arteries.
- [05:07]
Dr. Gabrielle Laing
Do we know if we take smoking out of it, do we know what would be the biggest contributor of heart disease?
- [05:15]
Dr. Michael Twyman
It's probably pretty close between dyslipidemia and high blood pressure. You know, lipids gets a lot in the headlines because there's a lot of dietary interventions. Some people can do that, make their lipids change. But Blood pressure is really that silent killer. You don't feel it often. You know, if you're starting to feel your blood pressure, it's pretty bad, usually pretty close to having a stroke or going blind. So it's really called the silent killer for a reason. Your organs are getting pounded with this high pressure for years and just starting to age faster than they should.
- [05:43]
Dr. Gabrielle Laing
How would someone know that? Do you feel heart disease generally?
- [05:49]
Dr. Michael Twyman
No. I mean, the unfortunate fact is that when people have heart attacks, that's often the first symptom that they had heart disease. If you're having chest pain, 10 tightness in your chest with exercise, severe shortness of breath, or exercise intolerance, those are often signs that you're developing severe atherosclerosis in your coronary arteries, the arteries that provide the nutrients to the heart. But typically, you're not going to have that sensation until your arteries are blocked 70 to 80% with plaque. So most people have no symptoms until they're pretty late to the game.
- [06:19]
Dr. Gabrielle Laing
You know, Matt, my producer and wingman over there, we were talking about exercise, and then we were talking about obesity and heart disease. And Matt was saying, you know, if someone is struggling with obesity, they have a much bigger body mass and the heart has to work so much harder. When you add in exercise, is that safe? How do we begin to think about introducing exercise without overloading the heart?
- [06:53]
Dr. Michael Twyman
That's a great question. And if somebody has truly been sedentary for many years, oftentimes they probably should consider a cardiac evaluation to make sure that they're going to be safe enough to really push it hard with exercise. You know, if they're doing bodyweight exercises or walking, I'm not really concerned for those people. But if they're saying, hey, I really want to get into HIIT training, I really want to get into heavy lifting. Okay, show me that your heart and your cardiovascular system can tolerate that. And that may be as simple as just, you know, getting an evaluation. Okay, what is this person's blood pressure? Maybe they do a CT coronary calcium score. Like, do they have hard plaque in their arteries already? And then for some people, you would actually consider doing a stress test. And stress tests are good tests. If people are having symptoms, as I said before, somebody has a 70% blockage in their arteries, you're usually going to be able to pick that up with a stress test. But stress tests are no guarantee that you're at risk for a heart attack. If you pass a stress test, you can still have a heart attack later that day. But they can give somebody an idea of their exercise capacity. So put them on a treadmill. It's often it's gonna be the Bruce protocol, where every three minutes, treadmill goes a little bit higher and a little bit faster. And you push them until they say, I can't do this anymore. Or you see some EKG chain to say, hey, stop. But if they can't go seven minutes on that stress test machine, they have pretty low functional capacity and they're gonna have to work out from there. But just making sure you're not seeing some high risk findings while they exercise.
- [08:06]
Dr. Gabrielle Laing
What would be a safe way to incorporate exercise? Someone is listening to this. Maybe they have seen a cardiologist, maybe they haven't. Is it safe to start with cardiovascular activity? Is it really based on the pace or the heart rate, or would it be better to lift weights? Is there some kind of standard?
- [08:28]
Dr. Michael Twyman
I would say it's probably a combination of kind of perceived exertion. There's the borg exertion scale, 10, 10. You're only able to do this for a few more seconds. The tiger's chasing you. Or is this a pace? You could do it all day long if you had to, but when you start kind of losing your breath, that's when you start getting to probably 70% or so of your maximal heart rate, when you really can't maintain it much longer. If you kept going higher and higher than that. So if you get to the point where you have a little bit mild breathlessness, probably okay. But if it's severe or you're getting tight in the chest, you got to really back it off and get that worked up first.
- [08:59]
Dr. Gabrielle Laing
And when would someone think to go to the emergency room?
- [09:05]
Matt
Right?
- [09:05]
Dr. Gabrielle Laing
Because if heart disease and heart attacks are really as robust and prevalent as we believe that they are, it seems as if they can be fatal. How many heart attacks are fatal?
- [09:19]
Dr. Michael Twyman
I mean, it used to be about 50% of people had heart attacks. You know, that was their first sign, and they didn't make it to the cath lab. So, you know, higher percentage than it should be.
- [09:29]
Dr. Gabrielle Laing
When should someone go see a doctor?
- [09:32]
Dr. Michael Twyman
But your question about the ER, I mean, there's like over 8 million presentations at the ER a year for chest pain. And you got to rule out the bad actors. Is it a heart attack? Is it a blood clot in your lungs? A pulmonary embolism? Is it an aortic aneurysm where your arteries are tearing? You know, is it a pneumothorax? You know, but, you know, three times out of four, it's not a heart attack. When people have chest pain coming to the ER and there's a lot of dollars spent working these people up. But if you're having severe symptoms where you feel like you have impending doom, you feel that there's an elephant on your chest, you absolutely can't breathe. If that doesn't go away in a few seconds, you gotta go in and get it checked out. Make sure it's not ST elevation, mi, where you've ruptured a plaque in your coronary artery. And those can often be fatal unless you're revascularized. But if you're not having symptoms, that's probably the better question, is who needs to be screened?
- [10:22]
Dr. Gabrielle Laing
And who would you say who needs to be screened?
- [10:25]
Dr. Michael Twyman
Essentially everybody. Everybody has a heart. It just what age?
- [10:28]
Dr. Gabrielle Laing
I don't know. That's questionable.
- [10:30]
Dr. Michael Twyman
Just what age and what test should you be really considering for those people? People with very strong family histories, My family included. My grandmother on my mom's side started having cardiac events in her 40s, had ultimately bypass surgery, strokes, had peripheral arterial disease, revascularization. She died at 63 from a stroke, way too young. My mom, she has a very high risk calcium score, but no symptoms, but well managed at this point. So people have strong family histories really should get checked out earlier. Probably under 40. I used to think 40 is kind of the starting point for many people, but I've seen more and more people in their 30s have very high risk calcium scores the past few years.
- [11:06]
Dr. Gabrielle Laing
And can you explain what a calcium score is and what does that mean to be high risk?
- [11:11]
Dr. Michael Twyman
So you have 60,000 miles of arteries. The coronary arteries provide the nutrients to the heart tissue themselves. There's a test called a CT coronary calcium score. It's a low dose radiation scan test that looks at the coronary arteries. And if there's calcium in the walls of the arteries. Calcium is supposed to be in your bones and teeth. If you have calcium in your artery walls, then that indicates that there's hard plaque in your arteries. The higher the calcium score, the higher the risk. So as you live your life, you can have a calcium score of zero. And I've seen people in their 80s with scores of zero. But I've seen a gentleman who was 36 years old who had a score of over 1400. That's extremely high for somebody at any age. But the journal cutoffs are over 400 on a calcium score is high risk, over 1000 is very high risk. And I always get asked, what's the highest score I've ever seen. 7770 was the highest score I've ever seen.
- [11:59]
Dr. Gabrielle Laing
You don't say. That is really, really high. The calcium. Where does the calcium come from? Is it dietary calcium that then gets deposited, or is it damage that then creates a cascade where calcium is then deposited in these arteries.
- [12:18]
Dr. Michael Twyman
It's kind of a in game where the body's trying to repair the damage to the artery. So on the top layer of the artery, there's something called the glycocalyx. It's a protective gel coating. Think of a fish coming out of water. That's slimy. That's kind of what your arteries are covered in. It's a carbohydrate gel coat. Underneath, that's the endothelium, one cell thick. If you took out all your endothelium, which would be very hard to do, it'd be about the surface area of six tennis quarts. And those are kind of like the protective barriers to the lining underneath called the intima. Once things start getting deposited in the intima, then you're off to the races. Developing plaque in the arteries. And the body's repair mechanisms will include depositing smooth muscle into the arteries and eventually calcium. Think of it as, like just forming a bone to kind of solidify that plaque to prevent it from rupturing.
- [13:04]
Dr. Gabrielle Laing
You know, it makes me think the vasculature of the heart has. Has a mechanism if there's damage, and that's calcification. I don't know what that mechanism would look like in skeletal muscle. You know, I mean, because it seems like the body has these very interesting processes to protect itself. And the calcium deposit isn't. It's not the cause. It's the response to whatever's happening.
- [13:37]
Dr. Michael Twyman
Right. It's the scar, essentially.
- [13:39]
Dr. Gabrielle Laing
Yeah. You know, and in the brain, there's tau proteins. It just makes me think, what is that like in skeletal muscle? Again, I don't know, but it's just. It's something to think about. How long have you been a practicing cardiologist?
- [13:56]
Dr. Michael Twyman
I finished my fellowship in 2012.
- [13:59]
Dr. Gabrielle Laing
Okay, so that's a while. And you did your fellowship in preventive cardiology?
- [14:04]
Dr. Michael Twyman
The fellowship was in general cardiology. I graduated and was an invasive cardiologist for many years. So I was doing heart procedures in the cath lab, you know, doing angiograms to determine how much blockage people had in their arteries, but eventually got more interested in the preventative side of things.
- [14:19]
Dr. Gabrielle Laing
In the last few years. Now, by the way, you are Wearing blue. Would those be blue light blocking glasses?
- [14:26]
Dr. Michael Twyman
They are.
- [14:27]
Dr. Gabrielle Laing
Now, this is a very different version. If you guys do not know Dr. Michael Twyman, who again is my cardiologist and it is. He is the guy that we send everybody to. Since I've known you, which. How long have I known you now?
- [14:39]
Dr. Michael Twyman
I think it was around 20, 19.
- [14:41]
Dr. Gabrielle Laing
Okay. I have never seen you without those orange lens glasses.
- [14:46]
Dr. Michael Twyman
Unless I'm outside. I usually have them on.
- [14:48]
Dr. Gabrielle Laing
Why?
- [14:49]
Dr. Michael Twyman
Helps with my circadian rhythms, helps with my sleep. So sleep's very important.
- [14:54]
Dr. Gabrielle Laing
No, don't know about that. Hard pass on that one. But do you wear it for sleep circadian biology or does it affect. Do you think it affects cardiovascular disease?
- [15:06]
Dr. Michael Twyman
I think it does. I think it helps mainly by optimizing your circadian rhythms so that you're able to sleep better. And when you sleep is when you repair your mitochondria. And I've had a sleep tracker for at least nine years and I've just noticed my data would always be better when I would do this. And the main thing is you're evolved to be under full spectrum light. So we evolved to be outside in sunlight. We were never evolved to be in front of artificial light that tells our body it's different times of day than it is. So I'm always just trying to let my body know, okay, it's daytime versus it's about to be evening. It's evening time. And these daylight glasses just help my body stay in that kind of rhythm.
- [15:45]
Matt
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- [17:13]
Dr. Gabrielle Laing
Talk to me about red light therapy and photobiomodulation.
- [17:18]
Dr. Michael Twyman
So photobiomodulation is using light therapy to change your biology. The target of red light therapy is the mitochondria and there's various devices, but skin contact is better because the major issue with light therapy is the acronym RATS. Light reflects, bounces off the skin. So where like 60% of it just bounces off, the light's absorbed, the light's transmit it. Which with red light therapy it's not going all the way through, it's not an X ray, or the light's scattered. The light comes in, bounces around and maybe gets in the mitochondria or maybe it bounces and goes back out. So you want to try to maximize how much light's coming in. So ideally the devices on the skin or as close as possible as recommended by the manufacturer. But once the light comes into the tissues, the main location where it's working is the mitochondria. The mitochondria absorb the red and infrared light. Cytochrome C oxidase for the geeks out there. And that does a couple things. It releases nitric oxide from the mitochondria, it increases ATP, which is an energy currency in the mitochondria, and it decreases reactive oxygen, speed species and has, you know, multiple thousands of studies. Most of it's going to be based off of, you know, musculoskeletal injuries and repair, but it helps lower pain, inflammation decreases swelling, helps tissue regrow.
- [18:33]
Dr. Gabrielle Laing
So wait, it helps tissue regrow. So hold on, we gotta, we gotta, we gotta rewind on this photobiomodulation, red light therapy. But it has to be on the skin like those masks, because I sit in front of panels all the time.
- [18:48]
Dr. Michael Twyman
So most the trials are using laser technology and then later led. But that's the challenge is how do you know what dose you're actually delivering. And that's what's challenging with, I call it the wild West. The red light companies right now is because there's a lot of claims out there what their devices can do, but you need to know a few things. You need to know the wavelengths, what color of light is coming off of the device. It should probably be some form of red and infrared.
- [19:13]
Dr. Gabrielle Laing
What are the wavelengths that you look.
- [19:14]
Dr. Michael Twyman
For there's many, but, like 660, generally in the red, 810, 850 in the infrared spectrum. Then you got to look at what's known as the power density or the irradiance. That's how many photons of light are coming out of the device divided by the beam area. So are you using, like, a pinpoint type of thing on the skin or using a big panel?
- [19:35]
Dr. Gabrielle Laing
I've been to your office.
- [19:36]
Dr. Michael Twyman
Yes, you do.
- [19:37]
Dr. Gabrielle Laing
And you have the world's largest panel. How. How big is that panel?
- [19:42]
Dr. Michael Twyman
Eight feet tall by four feet wide.
- [19:43]
Dr. Gabrielle Laing
Okay, number one, that looked very expensive. And number two, did you test the radiance?
- [19:49]
Dr. Michael Twyman
I don't have a laser power meter. And that's what you would have to have to actually accurately measure it. But, you know, when they said that everything has to be at least 100 milliwatts per centimeter squared to get benefit, that's not true. You know, most of the trials, at least in the cardiovascular world, you know, they're using, like, 10 milliwatts per centimeter squared. So you don't need these high irradiances to get the benefit. So you have to know the power density. So, like, how many photons of light are coming out and then the time. How long are you using that device for? And then that equals basically the dose, and the dose is different for the tissue types. So there was a cardiac trial more, kind of limited in scope, but very interesting was it was an Israeli trial where. Where they took patients who were having ST elevation in my eyes or having the worst kind of heart attack. They got rushed off to the cath lab. I believe there's 12 people in each group. Each group got standard of care. They all got stents, but half the group got photobiomodulation during the procedure. A day later, and three days later, it was a device that was utilizing 10 milliwatts per centimeter squared. They used it for 100 seconds, one joule. This is what's interesting. It was not over the heart. It was over the tibia, so their leg bones. Why would you do that? There are stem cells in those tissues. What they'd studied is that they gave the dose during the case. Day later, three days later, the people who got treated had troponin levels that were approximately half those that weren't treated. So troponin is a protein inside of the heart that gets released when the heart cells die. So when the heart cells die, it's like popping a balloon. All the contents spill out if you measure troponin in the blood, heart tissue is getting damaged and high enough levels can indicate a heart attack. So the people had half the size of heart attacks when they got treated. Everybody got the same treatment. Otherwise, how would that work? Well, when the stem cells are activated, potentially that's helping lower inflammation in the heart. You're also putting energy into the system while the heart is starving of energy because there's no blood flow going downstream. Proof of concept. Study only at this point. Safe to use it, but very interesting to think about that they weren't even treating the heart. These people had, quote, smaller heart attacks. So this is why photomodulation was really fascinating for me. It's like, you know, I'm a cardiologist. But where can most people use it? It's musculoskeletal injuries. That's where most of the data is at. So if you get injured and you can't train one, that sucks. But two, then you're not going to be able to get the cardiovascular benefits long term if you keep getting hurt. So this potentially helps you recover faster and get back into the game.
- [22:18]
Dr. Gabrielle Laing
You mentioned that it has to be on the skin. Can the red light penetrate through the skin?
- [22:27]
Dr. Michael Twyman
It's preferable to be on the skin.
- [22:29]
Dr. Gabrielle Laing
If possible, but can it penetrate to muscle?
- [22:32]
Dr. Michael Twyman
So infrared light at best probably penetrates 3 centimeters. Most data shows that like maybe 5 millimeters is kind of a red and then infrared start to hit, but maybe up to three. But think of it as like a lot of photons at the top of the skin and then only a few getting down deep. So that's why it's kind of the recipe. So again, the time is important because you could use a high irradiance for one minute, you could lose a low irradiance for a longer period of time and get the same dose. So it's kind of the analogy of like cooking a turkey. Do you go low and slow or do you drop the thing in a boiling pot of water and fry the thing?
- [23:09]
Dr. Gabrielle Laing
But is it the effect on the skeletal muscle or is it the effect on other areas that then generate the help of the tissue?
- [23:17]
Dr. Michael Twyman
It's decreasing pain receptors, it's decreasing inflammation, it's decreasing swelling in the tissue. And it's potentially that swelling in the tissue, particularly around the nerves, that causes some of that delayed onset muscle soreness. And so this is why you potentially want to use it after training. Now there is some debate on like, what is the perfect time after training? Because if you immediately run to the red Light panel after you do, you know, strength training exercise, you know, you might blunt that inflammatory adaptation. You might not be as sore, but you might not get as much hypertrophy if you use it immediately afterwards. Same stories like why you wouldn't do a cold plunge immediately after doing a strength training episode.
- [23:57]
Dr. Gabrielle Laing
You know, I've thought a lot about that and I would say to be fair, the influence might be really small. You know, like, I don't know if someone. If you're going to use red light, I would, from my perspective, go ahead and do it. I don't think it's going to affect their.
- [24:14]
Dr. Michael Twyman
I don't think it's big enough for most people to make a big deal. Like, you know, if you're an Olympic athlete, maybe you need to time it down to the minute. But I also get asked, like, what time of day. Think of these devices almost as a joke, as a sunplament. Like sun up to sunplament, sun up to sundown is when you ideally would like to use the thing. If you use an evening time, you just gotta be mindful that in some people it's not the wavelengths of light, it's the intensity, the lux that affects their sleep. So if you blast yourself, particularly in the face with these panels, 20 minutes before you want to go to bed, it might affect your sleep in some individuals. Other people has no effect. Some people, they sleep better with it. You just have to be kind of a biohacker and see what time of day works best for you.
- [24:49]
Dr. Gabrielle Laing
You know, I was looking at some data. It seems that there's a potential for certain red light to improve eyesight. Is that true?
- [24:56]
Dr. Michael Twyman
It is true. I don't know which irradiances they were using in those trials, but it's a very short period. I believe that the treatment session is only like three minutes long.
- [25:06]
Dr. Gabrielle Laing
Where else would you use various lights? When I. We were upstairs, all of us, and you pulled out this device again, I feel like it's Christmas when you come over, because there's all kinds of gadgets, although you should leave some here.
- [25:20]
Dr. Michael Twyman
Yes, I did.
- [25:20]
Dr. Gabrielle Laing
And you said, oh, this is cool. You put it on because it's blue light.
- [25:25]
Dr. Michael Twyman
So blue light doesn't penetrate the skin very deep. So it's for topical use only, so the dermatologist will know about its benefits. So it can help treat acne, but on skin contact it may help liberate nitric oxide. And that's obviously one of my areas of expertise and interest, is that anything that can improve nitric oxide maybe helps Arterial elasticity or blood pressure. So I bought these wearable patches a couple years ago and played around with them. I haven't done enough data with them to say that they absolutely release nitric oxide yet, but theoretically. But I thought it was pretty interesting when I was reading up on them, is how they kind of show that they did work, is that they got some recruits, probably some college students, paid them 20 bucks and they made them stand in front of a tennis serving machine and they blast them at 80 miles an hour in their quads. And so I was like, I don't know if I'd do that for 20 bucks or whatever they paid them. But half the kids got the light patch. The other kids didn't. They got, you know, here's some Motrin, some cold packs. But the people who got light therapy, they had like 40% smaller bruises the next day because it helps break up the hemosiderin. So it just helps speed up that wound recovery.
- [26:28]
Dr. Gabrielle Laing
People talk about red light for wrinkles. All those red light masks, which, by the way, I think I have three or four. Does blue light help with wrinkles or skin integrity?
- [26:40]
Dr. Michael Twyman
It would actually probably make it worse. Blue light is oxidizing to the skin. This is probably why people who have.
- [26:46]
Dr. Gabrielle Laing
Okay, so don't put that patch on your face.
- [26:47]
Dr. Michael Twyman
Yeah, do not put that patch on your face. And this is probably the reason why, when people have a lot of screen time, they tend to get a lot of fine wrinkles. Is that blue light is dehydrating their skin and it's oxidizing.
- [26:56]
Dr. Gabrielle Laing
I didn't know that. Hey, team, did you know that? Absolutely not. So do you put a flux on your screen?
- [27:04]
Dr. Michael Twyman
I usually have different software on my computers that pull it out. And then if you've been to my office, I always have in the corner, I have a red light panel that's on at that distance. It's not really for photo by modulation, but it's trying to balance out the spectrum of light that's in my office. So that red and infrared light's kind of bouncing off my computer monitor back into my eyes.
- [27:22]
Dr. Gabrielle Laing
Could you protect your skin and eyes with some kind of panel over your screen? It's hard because it penetrates the screen. But if someone were to come to you and say, hey, I want to protect my eyesight, I want to protect my skin. What do we do?
- [27:37]
Dr. Michael Twyman
So I don't know the companies that make it anymore. The one I used, I think went out of business, but. But they used to make these, like, orange acrylic plates. And then you would just physically put them in front of your monitor. For the people who don't want to wear the glasses for any reason or they.
- [27:53]
Dr. Gabrielle Laing
Birth control over here?
- [27:55]
Dr. Michael Twyman
Yeah, like it's like the Marine recruits with the birth control glasses. No, it was, you know, the case where, you know, I got some of them because, you know, I have nieces and nephews and they're not wearing these glasses. So I was like, would they put these in front of their, you know, like an old school screen protector? Some would, some wouldn't. But you know, there's always options. But the physical blockers, they work well. And then, you know, it's just being mindful that try to use some red light therapy. When you're using a lot of blue lit devices, does it have to be.
- [28:22]
Dr. Gabrielle Laing
Red light therapy or could it just be a red light lamp?
- [28:24]
Dr. Michael Twyman
The lamp is just helping more kind of balance out the spectrum of light in the room. But if you have the red light mask or you have a panel, it doesn't have to be skin contact for the face mask, but that helps stimulate collagen production, which is decreasing the wrinkles. That's why it works.
- [28:38]
Dr. Gabrielle Laing
But I mean, so for example, like last night I'm working on this book. I have to turn in my edits and I put the nighttime screen situation on. You know, you can switch it on your Mac, but I also use a little lamp. It's not red light per se, with infrared and, you know, all of that massive, intense red light, it's just a little lamp. Is that helping to balance out the blue light or is it just something. Yeah. How does that work?
- [29:18]
Dr. Michael Twyman
I would say that that it's helping balance out the blue light and it's just helping maintain your circadian rhythm. So you want to dial down the intensity of the light post sunset, Say yes.
- [29:28]
Dr. Gabrielle Laing
Are there things that you've now introduced into your practice, say, over the last two years? I know that you're talking a lot more about nitric oxide. You're talking a lot more about this endothelial glycocalyx, which nobody can spell. What is new on the horizon that you've really landed on?
- [29:49]
Dr. Michael Twyman
I think the tough glycocalyx is the biggest thing over the past couple years is that when I kind of transitioned out of traditional cardiovascular care. Where you're more reactive and now I'm a little bit more proactive, is you kind of go down that pathway where you find functional medicine and you realize that nutrition and exercise are extremely important. And there may be some supplements and instances that are helpful. But eventually you realize that that's not the whole story. And so then you find maybe the biohackers and the circadian biologists and you start doing some of those things. But once I was down that pathway, I came upon Dr. Mark Houston, Dr. Nathan Bryan, and they really taught me a lot about how nitric oxide was important to the vascular system that is released mainly from the endothelial lining. But in the past few years, it's been noted that there's another layer called endothelial glycocalyx. It was first visualized in the 1960s, but only past few years is it getting a lot more attention as people have potentially treatment options for it. And some of the diagnostic testing that I offer in my office or potentially you can do at home that can tell you the health of that glycocalyx and underlying endothelial layer. I think that's where really it starts, is that if you have a healthy layer of glycocalyx endothelium, it's not that your arteries are completely bulletproof, but it's much less likely you're going to develop severe atherosclerosis. And I think cardiology is doing a great job treating people when they have the end stage disease, but sometimes it gets a little bit too lipid focused and lipids are important. I'm sure we're going to talk about them today. But if you keep the glycocalyx endothelial healthy, you don't have to worry so much about the downstream effects.
- [31:17]
Dr. Gabrielle Laing
Does what I'm hearing you say is that this endothelial glycocalyx is really at the root. For example, I believe muscle is the root and health of skeletal muscle is the root. You believe, and correct me where I'm wrong, that the endothelial glycocalyx is in part really the root. And if you can address the health of that, then things like lipids, LDL cholesterol, APOB are important, but not necessarily at the root of heart disease. Is that what you're saying?
- [31:51]
Dr. Michael Twyman
Correct. I think it's too myopic to focus on one risk factor. Focus on the layer that is the first line of defense. It's your force field. If your force field is healthy, you're not likely to develop plaque in the first place. Place. Or if you've already developed plaque and you've picked that up on a calcium score or a CT angiogram, if you repair the glycocalyx and the underlying endothelium you stop laying down plaque and then you have the potential for plaque regression, which I know that's going to be a question, you know, can plaque be shrunk or regressed? The answer is yes, but you have to stop doing the damage first. And in part that's improving the nitric oxide pathways that help support that enthylglycocalyx.
- [32:31]
Dr. Gabrielle Laing
How can someone who is at home listening going, gosh, my mom had a heart attack and she had a heart attack really early. I am just entering menopause and menopause seems, there seems to be major changes in LDL cholesterol, apob, all kinds of things. And they're thinking, well, how can I measure if my endothelial glycocalyx, not that I can spell it, but how can I make measure it?
- [32:57]
Dr. Michael Twyman
Sure. We can just call it the EGX going forward, if you like that.
- [33:01]
Dr. Gabrielle Laing
Or E G X.
- [33:03]
Dr. Michael Twyman
Yes. So there's not a direct way you can actually measure the EGX at this point. There are some more research options where they're using certain type of intra vital microscopes, typically in the sublingual space where they're looking at the how? Well, the red blood cells are basically repelled from the glycocalyx in the blood vessels under your tongue and that correlates with what's potentially going on in the rest of your 60,000 miles of blood vessels. So they have done that for sepsis. And there are some tests that are still research where they look at the glycosaminoglycans, the gags that come off of the glycocalyx when it's damaged. So you can pick that up in blood and urine. But at this time there's not a commercial lab that does those tests.
- [33:46]
Matt
In my emails to stay up to date, I always get these medical lectures and I recently listened to a lecture from an academic, MD, PhD about magnesium. I have to tell you, it completely, completely changed my perspective from a scientific point of view on magnesium, one of the most common causes of headaches, you won't believe it is a magnesium or could be a magnesium deficiency. And you can test for this in the blood. There are hundreds of biological processes that magnesium is responsible for and the absorption in our diet is not great. And after listening to this lecture, I am more convinced than ever that taking magnesium can be great helpful. Also, 75% of Americans are deficient. That means three out of four of you listening to this podcast may be deficient. And that's where melo magnesium comes in. It's a daily super blend that contains the three most bioavailable and nutrient dense forms of chelated magnesium and not to mention over 70 trace minerals. Full transparency. Ned shares all of its third party lab reports. So you know that the product that you are ingesting has what it says it has. So if you are someone like one of the 75% of Americans who are magnesium deficient, go to helloned.com that's h l l o n e d.com doctorlion and they have amazing, amazing small travel packs of this magnesium, mellow magnesium. You will love it.
- [35:20]
Dr. Michael Twyman
So you have to kind of look down to where the endothelium is and again, that's one cell thick layer that lines your entire artery layer. It's kind of like the air traffic controller which determines what stays in your blood and what gets into the walls of the arteries. And testing that can look at that is, you know, one you could do. Blood pressure. If your blood pressure is normal, what.
- [35:37]
Dr. Gabrielle Laing
Would you define normal?
- [35:39]
Dr. Michael Twyman
Normal is under 115 over 75.
- [35:41]
Dr. Gabrielle Laing
115 over 75, that should be optimal.
- [35:44]
Dr. Michael Twyman
120 radius normal.
- [35:46]
Dr. Gabrielle Laing
Oh my gosh. So I've got Julia here, she's on my team. Julia, what's your blood pressure?
- [35:53]
Dr. Michael Twyman
I think it's 112 over, like 68.
- [35:56]
Dr. Gabrielle Laing
112 over 68, that'd be awesome. Well, so what is it?
- [36:01]
Dr. Michael Twyman
115, 75 is where once it starts getting above that, the risk of atherosclerosis increases.
- [36:07]
Dr. Gabrielle Laing
But do some people have a higher vascular tone? Because I'm going to measure my blood pressure. You're going to measure it actually with your very fancy machine that you've, you always come. I love it when you come to visit because you have about 15 obscure items that could probably save my life on a plane.
- [36:25]
Dr. Michael Twyman
That's the plan. Yeah.
- [36:28]
Dr. Gabrielle Laing
That number this 115 over 75. So if someone is at home and they're thinking, well, how do I measure their, how do I measure my own blood pressure? They need to sit down for 15 minutes at least.
- [36:39]
Dr. Michael Twyman
Five minutes.
- [36:40]
Dr. Gabrielle Laing
Five minutes. No caffeine, right?
- [36:42]
Dr. Michael Twyman
No caffeine, no nicotine. You know, feet up, feet on the ground, back supported, arm at heart level. And on the bicep, take away from the ones that are on the wrist because they're generally highly inaccurate. So on the bicep, take a measurement, record the number and look at trends. One number is not the problem, it's the blood pressure load. And so if you're consistently, you know, over 140, over 90, you need to talk to your doctor. Potentially, you're going to need to be on pharmaceuticals while you're working up the root cause why your blood pressure is so high. But that is just one sign that potentially have low nitric oxide availability is if your blood pressure starts to rise. There's test strips. These salivary nitrate test strips. They look like litmus paper. You put them in your saliva, the brighter red they are, the more nitrates you're potentially getting in your diet. So think beets, green leafy vegetables. Those compounds conventionally become nitric oxide in your stomach. And then there's pulse wave velocity, which is essentially a marker of how small, stiff the arteries are. So the oura ring can measure it. I have a device over here called the I heart that can measure it. So the arteries, when the blood comes into them, it's kind of like an accordion. The blood expands them and then they snap back. And these tests can measure are the arteries really elastic or are they really stiff? Are they like a lead pipe? If your arteries are getting stiff, your arteries are aging faster than you are on the outside.
- [38:00]
Dr. Gabrielle Laing
115 over 75. And is that across all age groups?
- [38:05]
Dr. Michael Twyman
That's the cutoff where we start going. Above that, the risk of vascular disease starts to increase.
- [38:09]
Dr. Gabrielle Laing
But what about. So I did my fellow. You know, you're from St. Louis. I did my fellowship in geriatrics, and we kept the geriatric population closer to 13090, maybe even higher for cerebral perfusion. For someone listening or watching, that's blood flow to the brain.
- [38:30]
Dr. Michael Twyman
Correct. And those trials, like the SHEP trials in the past, that was what was thought is that let the older population run a little bit higher. But more recent studies, the sprint trial, had shown that irrespective of age, 120 radius is really the goal for treatment.
- [38:45]
Dr. Gabrielle Laing
Dang. Speaking of treatment, what is nitric oxide?
- [38:52]
Dr. Michael Twyman
Nitric oxide is a gas. It has a very short life. It's around for about a second, but it's a signaling molecule and a hormone. From a vascular standpoint, it was so important for its discovery in the vascular system that it won the Nobel prize for Medicine in 1998. For the three researchers who discovered that from a heart standpoint, nitric oxide helps with arterial dilation, so it helps keep blood pressure normal. It acts somewhat like Teflon, preventing the cholesterol particles, the white blood cells, from sticking to the artery in the first place. And I'm sure the question is going to be, how do you improve nitric oxide? Well, in part, it's exercise as Blood's flowing across that artery lining that glycocalyx. It stimulates underlying endothelium to release nitric oxide. The arteries dilate sunlight, particularly the wavelength of uva. When that hits your skin, the nitrates are liberated from the surface of the skin, releasing nitric oxide. And then dietary wise, it's mostly the green leafy vegetable. So spinach, kale, arugula and beets. As those nitrates come into your oral pathways, you chew them. If you have the right oral microbiome, the oral microbiome, the nitrate reducing bacteria break down. The nitrates, eventually becomes nitrites, and if you have stomach acid, becomes nitric oxide. So those are the three big lifestyle things that can boost nitric oxide. And then there's various nutraceuticals and pharmaceuticals that can also help.
- [40:18]
Dr. Gabrielle Laing
And the way that someone would be able to tell if their nitric oxide is where it should be is test strips.
- [40:24]
Dr. Michael Twyman
Test strips are a starting point, but there is a caveat, is that if you have an oral infection, they'll be falsely, positively high. So you can't rely on just one data point. But if your test strips are low and white, sometimes it's the person. Maybe they're carnivore and they don't eat any vegetables, so they're not putting any nitrates in. Maybe they're a vampire and they never go out in the sun. Maybe they don't exercise. Okay, you have all these redundant pathways, but if they all start breaking, you're probably going to start developing vascular disease. And that gets picked up by your arteries, get stiffer on these pulse wave velocity testing. Or you can start seeing people's blood pressure start to rise and it can start rising just very mildly at the beginning. But if they go get tested, yeah, they may have low nitric oxide support them. Those things can be reversed.
- [41:06]
Dr. Gabrielle Laing
What is the most effective way? So if someone is coming in and their blood pressure is over, let's say it's 125 over 85 or something. So it's not grossly high, it's not emergent, and you give them a nitric oxide precursor. What kind of dose are we looking at? Because what I'm hearing you say is that one reason blood pressure, potentially one reason that blood pressure gets high is that people are nitric oxide deficient. Is that a right, correct word? How would we dose in behavior? Again, I understand that that's probably a very specific question. And some people, you know, are more sensitive to the diet and they might produce more. How do we go about dosing and course correcting blood pressure using nitric oxide.
- [41:59]
Dr. Michael Twyman
So I would start first with a good lifestyle history. Like, are they exercising? Are they eating the green leafy vegetables? What is their stress load? Double stress isn't bad. That's how we are resilient. But are you chronically stressed and not recovering from that stress? Do you sleep poorly? Are you not allowing your body to repair at night? So figure out, okay, is there some obvious lifestyle intervention you can utilize? If you've done all those things and don't see it, then that's where blood work can come in. Some people have high homocysteine. It's an amino acid that, when it's high, it affects some of these nitric oxide pathways. If you have high uric acid, for numerous reasons, you drink too much alcohol, you ingest too much fructose and have high uric acid. That uric acid can damage the glycocalyx, affecting the nitric oxide pathway. So sometimes it's getting to the root cause of what's causing the nitric oxide and removing that and the nitric oxide gets back into homeostasis.
- [42:52]
Dr. Gabrielle Laing
That is very helpful. I suggest everyone get nitric oxide strips just because it's fun. You'll be very disappointed at your nitric oxide levels. Most of us I know that I was. Tell me about. There's a lot of talk in the cardiology space about a few things. Number one, testosterone and cardiovascular disease. And also GLP1s and cardiovascular disease. You choose what you would like to talk about first. But again, this is very relevant. And then finally there was that study that was the keto CTA trial. So cardiologist choice.
- [43:34]
Dr. Michael Twyman
Let's go for the low T. Okay.
- [43:35]
Dr. Gabrielle Laing
Ooh, I love that. All right, talk to me about that.
- [43:39]
Dr. Michael Twyman
So something that, when I was in training, wasn't much discussed. I trained at St. Louis University for my internal medicine, and we did have a world famous geriatrician there, John Morley. He's the one that actually came up with the ADAM questionnaire, the androgen Deficiency in the Aging male questionnaire, which is so often used for people to figure out, like, are the symptoms due to low testosterone or not? He was a big proponent of it for people who were sarcopenic, which was a term that I only learned because I still had geriatric at slu. But that was something that, you know, I just put in the back burner for a while, did my cardiology training, and then started taking care of people who were more on the high performance end and they're you know, kind of super physiologic testosterone, like. Well, we know that that can be a problem. But what about people who are on the low side? Okay, what is the risk? Well, if you don't have a lot of muscle mass, you're probably going to be more insulin resistant, you may have more inflammation. So those are not good things. So I always look at is low testosterone something that first has an easily reversible cause, like the person sleeping four hours a night and abusing alcohol. Can you get them to stop those things? And testosterone is kind of a biomarker of are they doing the lifestyle things that could support a healthy testosterone level. But if they're doing all the right lifestyle things and their testosterone is 250 on a couple occasions and they have horrible symptoms, then it's reasonable to replace those people. But in the past it was thought that testosterone was going to be cardiotoxic and actually had a black box warning from the FDA for many years until the recent traverse trial came out. The traverse trial was done in men who were hypogonadism, middle age and above. And they were using topical gel preparation, which still is used but probably is not the most common way that most people replace testosterone. And it at least showed that people did not have more cardiac events when they're on testosterone didn't show benefit, but didn't show harm, which was a good thing. But some of the caveats for the traverse trial is that over 60% of the men who started testosterone stopped it before the trial was done, either because they felt better and they just wanted to come off and see what happened or the gel wasn't working well enough for them and maybe they went to something else, don't know. And the issue is that the doses that they put them on didn't really put them into really quote optimal levels. And there might be a range of where people say it's optimal, but 500 to 1000 is generally what I see kind of thrown around is that most people best around that they barely got these people up to like 350, 400 on gel. So did they get benefit? No, but they didn't have harm at the doses that they replaced them to.
- [46:13]
Dr. Gabrielle Laing
It's a really important point. And basically the traverse trial really addressed the risk benefit use of testosterone. And there has been this long standing belief, like you said, that and especially cardiologists, they, at least before I met you, for the majority of the cardiologists that I have known, they were very anti testosterone and anti hormones and that Seems like that's a bit outdated and always, again, takes evidence to kind of change people's minds over time. But what they found at the Traverse trial is that there was no increased risk of heart disease with the utilization of testosterone. And I think that there is evidence that low testosterone is a risk for heart disease.
- [47:02]
Dr. Michael Twyman
Absolutely. And they have higher calcium scores, they have higher risk of diabetes. You know, all cause mortality. So it's one of those things. Where is it a chicken egg? Is the low testosterone causing those things or is just that the person has so many comorbidities that their testosterone is so low? So one thing I sometimes explain to patients is that think about your heart and brain being very energy dense. They're going to take the lion's share of energy. If the body is kind of starting to fail, it's going to take away energy from the sex hormone cascade and say, we don't need to think about reproduction right now. We need to think about keeping your heart and brain alive. So your testosterone levels are going to be low for now.
- [47:32]
Dr. Gabrielle Laing
Do you think. Do you happen to know why they thought that testosterone utilization was contributing to heart disease?
- [47:42]
Dr. Michael Twyman
My understanding is that it was some poorly designed trials that had shown some potential increased risk. But when they actually went back and looked at the data, it probably was neutral at best. But because of those trials, the testosterone got a black box warning. And many cardiologists, you know, they're busy, you know, they're taking care of, you know, whatever. They're 40, 50, 60 patients a day. And if someone says it's a black box, they're like, don't use that stuff, and they move on. But the more interesting thing is, like, why is low testosterone a problem from a cardiovascular standpoint? Most likely it's because when you have low testosterone, you don't have the ability to aromatize it into estrogen. And it's the estrogen for men that's probably more cardio protective. When estrogen is in more optimal ranges, it helps support healthy nitric oxide levels. It helps support lipoproteins being more optimal. You need the estrogen for brain function, you need it for libido and bone health. So it's the estrogen that's probably the benefit in many of these guys.
- [48:38]
Dr. Gabrielle Laing
That's fascinating. And is there a range where you like to see estrogen? We have a range. I don't know. Is there a range that at least 30? Yeah. So we like 30 to 70. Or is it 70? It depends on the lab, but I would say at least 30. I think that that's a good range. You know, there was a period of time when everyone was on anastrozole and so that is in a somewhat of an estrogen blocker, decreases estrogen and people really felt terrible. So things are changing. What about GLP1 and heart health?
- [49:16]
Dr. Michael Twyman
It's very interesting. Yeah. When the drugs came out, you know, they're first approved for diabetes and at that point I was already a full fledged cardiologist and so I wasn't. I had many patients who were diabetic, but they had endocrinologists or internists or family practice doctors who were managing it. And most time the cardiologists were kind of hands off with their blood sugars at that point. And so I didn't really pay much attention when they first hit the market. I had a very wise attending when I was at SLU who said don't be the first doctor to use a drug and don't be the last one. So let's see how this plays out. So, great data on people who are diabetic, but I got my current practice launched up in 2019, busy taking care of people who are more proactive and I honestly probably on one hand can count how many diabetics I have in my practice. It's so few. So I see a lot of patients with insulin resistant prediabetes, but those aren't necessarily the patients who are going to be on GLP1s. So I didn't think much about it for a while, but went to the American College of Cardiology conference back in 2024 and the select trial had recently come out. And the select trial was looking at GLP1s, particularly semaglutide in patients who were not diabetic, they were just overweight and be what it is, you know, a BMI above 27 or 30. And these patients, you know, had known vascular disease, coronary disease. I had prior events but not recent events. And I believe it was like 17,000 plus patients were evaluated on the trial. And at the end of the, I believe it's 40 months, the people who were on treatment had about a 20% decrease in MACE, major adverse cardiovascular events. So it was the first trial in non diabetics that showed people had less cardiac events. And so that was really a game changer. And so the push is really to be more aggressive potentially with these medications in the right population. I don't think it needs to be in the water or everybody being using this stuff, but it should be more liberally used in Patients, particularly, who have known coronary disease.
- [51:09]
Dr. Gabrielle Laing
Known coronary disease, Is there a range and does someone not have coronary? Is there a spectrum? I guess is a better question.
- [51:22]
Dr. Michael Twyman
That's a great question. And that's one of the challenges that trying to apply clinical trials to the person who's sitting in front of you. The classic terms are primary prevention and secondary prevention. Most cardiologists are living in the secondary prevention world. So the person's already had a heart attack. You're just trying to help them not have another one. Very clear evidence. Use your statins, your beta blockers, your GLP1s. You know, there's a lot of new tools out there that can help those people not have another event. The real question really is the primary prevention people, the people who've never had a heart attack, stroke, stents, or bypass, how aggressive should you be treating those people? And there's a window is that if you don't look and you just plug people's numbers into a risk calculator, which can give some idea of, you know, risk. But I'm more of the mindset of, like, look at the arteries themselves. If you look at the arteries in this plaque, that person's high risk, irrespective of what some little calculator says. Start treating that person more aggressively, particularly if they have a strong family history. If your grandma started having heart attacks in her 40s, maybe the family should be screened a little bit earlier and treat it more aggressively for their blood pressure or their lipids. And so treat the person who's in front of you to the best of your ability, but base it off data. If that person has plaque in their arteries, they're at higher risk of having events down the road. And maybe they're not necessarily primary prevention anymore, and they're not secondary. They're maybe like 1.5.
- [52:39]
Dr. Gabrielle Laing
You know, there's a lot of backlash against statins. Could someone reverse heart disease with diet and exercise alone? Let's say that they have plaque and they have a greater than 400 calcium score. Could they do it with diet and exercise alone?
- [52:57]
Dr. Michael Twyman
Depends on where they're lipoproteins are starting with. And that's why I say it's one risk factor. You know, if you have a 90th percentile APOB, for example, you know, your APOB is 150 as diet and, you know, exercise going to get you down to an APOB of 70. There's no way. It's just not going to happen.
- [53:15]
Matt
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- [53:55]
Dr. Gabrielle Laing
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- [53:58]
Matt
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- [54:52]
Dr. Michael Twyman
There's so much genetic control for you having those levels that high most of the time. And we'll get into the keto CDH trial in a second. So those people, you can do whatever lifestyle interventions, but most people, unless they're on kind of like extreme dietary kind of platforms, you know, they're keto or they're extremely like high carb. Making dietary changes doesn't have the biggest driver to affecting their lipoproteins.
- [55:17]
Dr. Gabrielle Laing
Yeah, I was reading some data and it's really, it's interesting because we make these dietary guideline recommendations, e.g. cholesterol recommendations which dietary cholesterol has taken out of the guidelines in 2015. But the saturated fat percentage, when you think about those dietary influences, it's really 20% of people that seem to be really affected by dietary fat and just nutrition. It seems as if there's a genetic predisposition. Remember Bob Harper?
- [55:52]
Dr. Michael Twyman
Yes.
- [55:53]
Dr. Gabrielle Laing
For those of you listening, for my gen zers, Bob Harper was the trainer and the base loser. He was super fit, very healthy and he was running on a treadmill and he had a heart attack and he again 8 quote very healthy and it was, he had genetic hypercholesterolemia.
- [56:15]
Dr. Michael Twyman
He actually had lipoprotein little a. Oh.
- [56:18]
Dr. Gabrielle Laing
How high do we know? Don't know, and lipoprotein. Little a mike. Dr. Twyman can talk about that. Those are. It's a genetic marker. Again, there's a series of markers that we look for. L.P. aPOB, yes, LDL cholesterol, which will then bring us into this keto trial. Are there other markers? Would those be your top and what are they?
- [56:47]
Dr. Michael Twyman
So I usually kind of break it down into three big buckets. So I look at tests that affect your nitric oxide pathways. So uric acid, homocysteine, look at urine, microalbum and creatinine. Old school test to look to CDF2 kidney disease. But if you have protein in your urine, you're damaging the glycocalyx to the kidneys. So if you're damaging that, potentially you're damaging the heart artery once. So that's kind of one bucket. There's a few others like the celery, nitric oxide strips and blood pressure. Second big bucket is the oxidative stress and inflammatory markers. So HSCRP, Lp, PLA2 activity, which is a marker of inflammation in the artery, myeloperoxidase, which is a marker of white blood cell activation, which is potentially going to be damaging your HDL and the top layers of the arteries. Interleukin 6 is an inflammatory marker. And then there's a bunch of oxidative stress markers. So often start with ggt, gamma glutransferase. It's a test, simple. It's on a complete metabolic panel. But if the person has high ggt, they have low glutathione. If they have low glutathione, they have a lot of oxidative stress potentially. And they could look at oxidized ldl, oxidized phospholipid apob. If you look at those things, those people are at higher risk. And then you get into the lipids. So I usually start like that. It's like, okay, we heard the nitric oxide, where's oxygen inflammation? Now we'll take a look at the lipids. So, yes, I will still always look at the traditional lipid panel. It's free, it's included. So if the person's total cholesterol is over 300 and their LDL cholesterol is over 190, they potentially have familial hyperlipidemia. But the key keto CDHL. We'll talk about the lean mass hypersponders in a second. But I will look at their HDL cholesterol, but it's not really that predictive for most People, there's people with low HDL have heart attacks or people with high HDL that have heart attacks. But sometimes it's an insight into their metabolic health. And then their triglycerides, which generally I like to see less than 80.
- [58:39]
Dr. Gabrielle Laing
There's some genes less than 80.
- [58:40]
Dr. Michael Twyman
That's pretty low, that's pretty aggressive. But if it's not below 80, then you actually are looking like, is this person likely insulin resistant? Or what is their kind of carbohydrate tolerance? And then looking at the lipoproteins themselves, it's the lipid proteins that actually predict risk or particles predict risk is another way to say it. The cholesterol is just being transported in these lipoproteins. The lipoproteins can be measured directly. You can get an LDL particle number, but you can also look at apob or apolipoprotein B. So the example I use for patients is that the lipoprotein is a tennis ball. The cholesterol is going inside the triglycerides go inside vitamins like A, D, E and K and different phospholipids, which are building blocks for cell, all go inside these little tennis balls. But on the outside of the tennis ball, that white stripe, that's essentially apob. It's a structural protein, holds that thing together in a sphere and then acts like a little key to bind into different LDL receptors. There's Napo B on the outside of every LDL particle. There's an APOB on that side of lpla, vldl, ildl. So LP is very similar to ldl. It has an apob, but it has an extra protein, apolipoprotein A on it. And it's like a little corkscrew protein. And that protein allows it to kind of dig into that glycocalyx a little bit easier to damage it.
- [59:57]
Dr. Gabrielle Laing
What number would you want to see? Lp and when would you get concerned?
- [60:06]
Dr. Michael Twyman
So it's generally better to measure this. And this is the one challenge is that it's measured in animals or it's measured in milligrams and you want to go for the milligrams per deciliter variant and generally want to see it less than 75. Everybody has LPLA, but there's a genetic control with it where up to about 20% of population has higher levels than that. And it's almost linear. The higher lpla, the more vascular risk, and it can double your risk of having a heart attack or stroke compared to having normal levels.
- [60:35]
Dr. Gabrielle Laing
Do you think there's any way to predict who's gonna have a heart attack?
- [60:39]
Dr. Michael Twyman
Yes, but it's mostly based off plaque and vascular inflammation and low nitric oxide. You can just almost see the people who are gonna be the train wrecks.
- [60:47]
Dr. Gabrielle Laing
Oh, gosh. You know, we are gonna talk about the keto trial. I have a couple questions prior to that. Alcohol and heart health. Can people drink alcohol and have healthy hearts?
- [61:04]
Dr. Michael Twyman
The short answer is yes. But the question's always going to be what dose? You know, alcohol is a poison. You know, I tell people I'm definitely not a teetotaler. I have a very nice bourbon teetotaler person who doesn't drink alcohol. I'm not. You know, I have a very nice bourbon collection. I have a very nice wine collection. But it's measured at this point, I have to have a very good reason. Good family, good friends. Got to be a good celebration. I just had my 25th wedding anniversary. I enjoyed the wine pairings at dinner. It was great.
- [61:34]
Dr. Gabrielle Laing
Congratulations.
- [61:35]
Dr. Michael Twyman
Well, thank you. But is it heart healthy? That's a little bit more debatable. Nobody who's not drinking should take up drinking for some perceived benefit for their.
- [61:44]
Dr. Gabrielle Laing
Vast of the resveratrol of wines.
- [61:46]
Dr. Michael Twyman
Correct. They should not pick up drinking red wine just because they think it's going to be good for the their heart. That being said, is what is it doing to the person's sleep? That's probably the biggest concern is that alcohol, for many people, once they get over like one glass, it's going to start impacting their quality of sleep. And while you're unconscious with alcohol on board, you're not getting that reparative sleep. And that's the challenge. You're in a very low HRV the next day, likely with alcohol on board the night before. Does it impair your decision to go train the next day? That's the thing that I'm concerned about. When people have a routine alcohol habit.
- [62:18]
Dr. Gabrielle Laing
How come alcohol then really heavy alcohol use, this is what we are taught in training, causes cardiomyopathy, a bigger heart.
- [62:28]
Dr. Michael Twyman
It's basically it's an alcoholic cardiomyopathy. And I definitely saw a few cases of that in my career earlier. I don't know what the exact dose is, but it's somewhere in probably in the neighborhood of a 12 pack of alcohol every single day for weeks on end.
- [62:39]
Dr. Gabrielle Laing
Makes your heart. Yeah.
- [62:41]
Dr. Michael Twyman
Well, the alcohol directly poisons the cardiomyocytes and then the heart becomes weak and doesn't pump well.
- [62:46]
Dr. Gabrielle Laing
Oh gosh. What about caffeine? And I'M just asking for a friend that doesn't drink enough energy drinks to kill a draft horse. But yeah, ask him for a friend.
- [62:58]
Dr. Michael Twyman
Yeah, I mean, everybody has a different tolerance to caffeine. Generally, if people stay under 400 milligrams a day, probably can be pretty neutral from a vascular standpoint. So a cup of coffee has about 100 milligrams for.
- [63:10]
Dr. Gabrielle Laing
Not my coffee.
- [63:11]
Dr. Michael Twyman
Yeah, yeah, you have the super strong coffees. But not everybody who drinks coffee or caffeine from any source necessarily has any heart issues. But those that have palpitations, they feel their heart fluttering. You know, they're measuring their blood pressure and they're seeing the blood pressure going up. Or they have some of these fancy toys that look at arterial stiffness at a certain threshold. Everybody's already started to have some kind of impact. And then the other issue is sleep. You know, it blocks the adenosine receptor, so it affects how easily some people can fall asleep. So ballpark, 6 out of 10 people are slower metabolizer caffeine. So those people, they need a bit more careful with that, particularly on their timing. They should keep caffeine to earlier in the day so it has a better chance to start washing out of their system before they're going to bed.
- [63:55]
Dr. Gabrielle Laing
You know, I recognize that I didn't finish the, the question on statins, you know, because I was so excited about alcohol and caffeine. The if an individual shows calcifications, and again, we share many patients together in our medical practices. If they are given a statin, can you reverse that hard and soft plaque?
- [64:20]
Dr. Michael Twyman
It generally will not reverse the hard plaque, though I have seen some calcium scores go down on statins. Typically you actually see the calcium score going up on statins and the thought is that it's taking the soft plaque, which is more prone to rupturing and causing it to become more firm. And so the calcium scores will go up. If you do a calcium score test and then don't make any changes, the calcium score test will generally go up about 20% a year. If you'd make something that's really high.
- [64:45]
Dr. Gabrielle Laing
Yeah, it's 20% a year. No wonder everyone's dying of a heart attack.
- [64:50]
Dr. Michael Twyman
So that's why you got to look for it as early as possible and start intervening. Yeah, like I said, I saw a third six year old with a calcium score of nearly 1400.
- [64:57]
Dr. Gabrielle Laing
A six year old.
- [64:58]
Dr. Michael Twyman
36 year old.
- [64:58]
Dr. Gabrielle Laing
36 year old.
- [64:59]
Dr. Michael Twyman
And so that person, it didn't happen in from 35 to 36 had been happening since Brian's 20s. So the sooner you can find it, the sooner you can start intervening. But if you do an intervention and you see a calcium score stay about no more than 5% increasing, you probably got ahead of the game and you've stalled that plaque buildup. And there's a chance that the salt plaque will shrink, but you're not going to see that on a calcium score dash. You'd have to do the CT angiogram to see that part.
- [65:23]
Dr. Gabrielle Laing
How do people then, you know, when we talk about regression, what are we talking about?
- [65:29]
Dr. Michael Twyman
Generally talking about the. The lipid rich cores of the plaque shrinking down. So you can think of the plaque as almost like a pimple and it has a thick cap over it. Hopefully the ones that have thinner caps over it, they're more prone to kind of opening up all that damaged cholesterol, white blood cells, the smooth muscles, all that stuff spills out into the blood and now the blood clots. And you go from having a 50% blockage to immediate 100% blockage as the platelets are sticking in that area. And that's what essentially most heart attacks are. The statin is helping that lipid rich core shrink and also putting a thicker cap over that plaque so it seals it off.
- [66:05]
Dr. Gabrielle Laing
Does heart disease cause erectile dysfunction?
- [66:09]
Dr. Michael Twyman
Absolutely can. So the analogy is ED equals ed. So erectile dysfunction equals endothelial dysfunction and vice versa. So if guys are starting to have issues with erections, oftentimes it's a vasculogenic cause. They're not getting enough blood flow into the sexual organs to allow an erection to happen. And it's due to low nitric oxide.
- [66:28]
Dr. Gabrielle Laing
When you see patients, how early does this seem to start?
- [66:32]
Dr. Michael Twyman
Ed can happen under 40, but it tends to happen more when people are referring to 50, 60 years old.
- [66:37]
Dr. Gabrielle Laing
And do you treat with vasodilators or do you use agents like Cialis? As a cardiologist, I do on occasion.
- [66:46]
Dr. Michael Twyman
It's kind of the canary in the coal mine. Question is that if guys are having ED and they're asking for, you know, the low blue pill or, you know, sildenafil or tadalafil, it's not that it's a problem that they need to use those things, but it's a marker that they don't have good nitric oxide to begin with. And that's somewhat of the myth, is that these are not nitric oxide promoting medications. They just keep nitric oxide around longer. You have to get the nitric oxide I call into the funnel. You have to be eating the greens, you got to be exercising, got to be in the sun. You got to be taking the nitric oxide promoters into the system. And then the Tadalafils and the Viagras, they just keep the nitric oxide around longer so that it has more effect on the vascular system.
- [67:23]
Dr. Gabrielle Laing
That's fascinating. I didn't actually know that. And in my mind, that seems like there could be a great combination of, you know, we use Cialis in our practice and Tadalafil. If you use that in conjunction with a, I don't know, beetroot juice or something like that, seems that seems like that would be very helpful. And just a real nerd note. Arginine increases nitric oxide.
- [67:53]
Dr. Michael Twyman
That is true, and I'll hit that one in a second. But that is a good point, is that those medications, they work. But I'm sure you've seen some non responders. You keep ramping it up, and they said this stuff doesn't work. Or by the time you get to the highest doses, they're having headaches or back pain. Like, I can't take this stuff. Well, maybe if you got the nitric oxide boosted up, you could use a lower dose and they get the effect. But the question about arginine is that the greatest majority of people are not deficient in all arginine. So what happens with arginine, which is an amino acid in the presence of oxygen, you need this enzyme called Enos endothelial nitric oxide synthase. The Enos enzyme converts the arginine into citrulline and nitric oxide. So you can shove all the arginine you want in the system, but if the Enos enzyme doesn't work, you're not getting nitric oxide on the backside. And a lot of supplements, that's all they are, is arginine. So if it doesn't work for the person, it's kind of a de facto that Enos enzyme isn't working. And after age of 40, that enzyme is significantly reduced in its capacity to kind of crank arginine into citrulline. So that's why you have to kind of back up with the oral pathway or sunlight or doing something else to support people. That's why vascular disease gets more prevalent as people's age, because that Enos enzyme becomes less and less functional.
- [69:07]
Dr. Gabrielle Laing
How do you know that?
- [69:09]
Dr. Michael Twyman
Lots of training and learning, and Dr. Nathan Bryan taught me that many years ago.
- [69:13]
Dr. Gabrielle Laing
And would someone supplement with the enzyme?
- [69:16]
Dr. Michael Twyman
You don't. Not the enzyme directly. You would supplement with things that could support the, you know, since I'm recoupling, turning back on or some of the product analogies. When they are lozenges, they dissolve, they release nitric oxide gas and that just gives it to nitric oxide directly without having to have that arginine pathway working.
- [69:34]
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- [70:49]
Dr. Gabrielle Laing
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- [70:51]
Matt
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- [71:06]
Dr. Gabrielle Laing
That's really fascinating. I. Can you do me a favor?
- [71:10]
Dr. Michael Twyman
Sure.
- [71:12]
Dr. Gabrielle Laing
I hear a lot about niacin and hdl. Someone very close to me came home and I found a bottle of niacin ordered off of Amazon. I'm not going to say who ordered it. Shane, my husband. And I said, honey, why are you taking that? And he said to me, well, the flushing and it improves my hdl.
- [71:41]
Dr. Michael Twyman
Both are correct. The flushing definitely is going to happen. That means it's actually working for those people. So for the people who are going to take niacin under the direction of their doctor, if you have the no flush niacin, it is not going to give you any type of cardiovascular benefit. You have to get the flushing because that means that the prostagland landins are being released. But the theory that using some type of supplement or medication to raise your HDL is going to have a positive cardiovascular benefit has not been proven. All the old CTEP trials show that when they use drugs to raise hdl, the people who got those drugs, they died faster than the placebo group.
- [72:16]
Dr. Gabrielle Laing
So you should throw out that niacin.
- [72:18]
Dr. Michael Twyman
Not necessarily. It's just that maybe it's neutral. But what dose are you going to use? I mean, most people aren't going to tolerate going up to like 2,000 milligrams of niacin, where, you know, most people need to if they're going to have a significant effect on their lipids. So I use it on occasion. It still does work for some people who are statin intolerant or just prefer not to be on a statin for any reason. But it's sometimes a harder drug or supplement to use because to get to the doses that work, most people have significant enough flushing that they're like, I can't tolerate this stuff.
- [72:45]
Dr. Gabrielle Laing
But to be clear, does niacin affect health outcomes with hdl? I mean, when I was looking at the data, I wasn't convinced. I felt like it might change hdl, but it doesn't seem to affect any significant health outcomes.
- [73:01]
Dr. Michael Twyman
That's the best way to probably explain is that, like, the HDL numbers will go up, but does that mean that the person has less heart attacks, stents, strokes, the things patients care about? Probably not. And I don't think any of the trials to date have actually shown that niacin does that.
- [73:13]
Dr. Gabrielle Laing
Do you think that there's anything that people are really missing that seems to be really toxic for heart health?
- [73:21]
Dr. Michael Twyman
Poor sleep?
- [73:23]
Matt
Don't say that.
- [73:24]
Dr. Gabrielle Laing
I have two little kids. I spent two and a half hours last night.
- [73:27]
Dr. Michael Twyman
Season of life, Seasonal life?
- [73:29]
Dr. Gabrielle Laing
Well, yeah, except my daughter is going on six and my husband's in residency.
- [73:37]
Dr. Michael Twyman
Right. You remember residency. Like the worst time of your life for sleep. I mean, you don't sleep in your own bed except for every, like, third night. And when you're working, working 36 hour shifts without sleep, you do because you have to do it. But in hindsight, you're like, that's like the worst thing you possibly ever could do from, you know, a health standpoint, long term. And so you do it when you're young, but once you realize that, like, hey, this is going to kill me if I kept trying to do this. You have to do something different.
- [74:03]
Dr. Gabrielle Laing
Okay. Aside from sleep?
- [74:05]
Dr. Michael Twyman
Yes, aside from sleep.
- [74:06]
Dr. Gabrielle Laing
Would it be, for example, people are really into CBD gummies or cbd? There's just a whole host of things that. There's always these evolving or, you know, the biocharger that's up in our bedroom. Thanks, Kim. Are there any items Whether supplement, substance, drug and or activity that someone would not necessarily think about being very damaging.
- [74:39]
Dr. Michael Twyman
I mean, the CBD one is interesting. I don't proclaim to be an expert. I have some patients that have utilized it. And I say that the biggest challenge is that like it's not regulated in a way where there's a standardized dose that you know, okay, like this dose from this dispensary is comparable to this dose from this dispensary. I'm at least relatively neutral for CBD from an anti inflammatory standpoint or if it can help the person sleep. But where the challenge comes in more is when there's more THC in the product. Now in certain instances it's beneficial if you have epilepsy. I'm not talking about that. Or if you have cancer. It's just like the general kind of use case for it. There's definitely some increased risk of increasing your triglycerides with it. There's increased risk of atrial fibrillation, which is a heart rhythm issue that potentially increases the risk of stroke. So something you probably don't want to play around with unless you have a strong medical reason to be on it.
- [75:23]
Dr. Gabrielle Laing
Thc. I see. Let's talk about the epic lipid inflammation and controversy of the keto CTA trial. So I'm gonna let you kick this off because I am certain that you've gotten a ton of questions.
- [75:45]
Dr. Michael Twyman
Yes. And I've seen many of these lean mass hyper responders over the years.
- [75:49]
Dr. Gabrielle Laing
And what is that?
- [75:50]
Dr. Michael Twyman
It's a phenotype where the person is lean. I believe the BMI has to be less than 25. They have no evidence of insulin resistance or prediabetes. And then on their labs they have this panel where before they went on to a low carbohydrate diet, their LDL cholesterol had to be less than 160mg deciliter. And they didn't have to have any genetic abnormalities with their lipids. They start a ketogenic diet, their LDL cholesterol goes north of generally 190. I've seen them as high as 500 in my practice. LDL is 500.
- [76:25]
Dr. Gabrielle Laing
But we're not before. Just.
- [76:26]
Dr. Michael Twyman
But not before.
- [76:28]
Dr. Gabrielle Laing
Understand this for the listener or the viewer. A lean mass hyper responder is someone who changes their diet, goes to a lower carbohydrate diet. And is it a higher fat diet or just low carb?
- [76:39]
Dr. Michael Twyman
It's low carb, but generally it's higher fat, high fat.
- [76:42]
Dr. Gabrielle Laing
And instead of improvements, technically they Shoot. Their cholesterol changes drastically.
- [76:53]
Dr. Michael Twyman
Correct. Their lipids look like they have familial hyperlipidemia. And now other parts of their traditional lipid panel. Their triglycerides are low, they're HDL high. And they will often say, like, well, I'm metabolically healthy, so this LDL cholesterol doesn't matter. Maybe, maybe not. And this is what they're trying to look at in this observational trial. Trial. I applaud them for at least looking at the arteries because in the past it used to be that, like, well, I don't have diabetes insistence, so I'm pretty protected from vascular disease. And it's like, I believe, yes, that there are other things that drive plaque in arteries other than just LDL cholesterol. But that is one variable that is like blinking red, like the check engine light's on. You got to go looking like, is it causing damage to the arteries? Because I used to get a lot of patients who would have this kind of phenotype. They go get just a calcium score and say, my calcium score is zero. So I don't have to worry about this. You don't have to worry about it right now. It may be in a year. But if you left your labs like this for the next 10 years unknown, you're likely to have more plaque in your arteries. It's based off of Mendelian randomization trials in the past that say that if your LDL cholesterol is here, you're more likely to have plaque. Doesn't mean that you're guaranteed, but it's risk. So it's like you drive your car, you don't expect to crash your car, but you wear a seat belt. This is sort of like if your LDL cholesterol is 500, if it's causing plaque in your arteries, maybe you want to do something about that LDL cholesterol. So at least in this keto CTA trial, they're actually looking at the arteries with more invasive or say non invasive technology. They're using a CT angiogram and then they're using the Clearly AI overlay on top of it. So clearly is a company that uses AI software to analyze the images and can quantify the type of plaque that's in the arterio. So I believe it was like 100 patients were in the trial. It's an observational trial. I think it was volunteers from kind of like a social media outreach. So it's a highly selected population of people who are motivated to see what's going on with their vascular system. And the interesting thing is that these people had been on this type of diet for a couple years and they've had these high lipids for many years and were untreated. So either they've gone to a doctor and the doctor said like, hey, I recommend you stop this diet and start meds, or they just said like, I'm not going to go to a doctor because the doctors can yell at me because my numbers are so high. So they get a CT angiogram at baseline, they stay on the keto diet, they confirm it by using the keto mojo strips and such, and confirm that they stayed on that diet for the full year. And then they repeat it, a CT angio at the end of the year. The primary outcome in the initial study was supposed to be how much change in non calcified plaque was present. So non calcified plaque is soft plaque plaque that's more potentially vulnerable to rupture and causing heart attacks. It's not the hard calcified plaque that's usually kind of a scar in the artery. So that was their initial primary outcome. But in the actual paper, they really kind of gloss over that and they focus more on that, like, well, these people had high apob and they didn't seem to have more plaque because of apob. But when you actually look at the actual graphs, the non calcified plaque increased in almost every person in the study, and it increased like 18 millimeters cubed of plaque in that timeframe, which would be more than what a kind of general healthy population would be. So it's still kind of early. Let's say it's observational, it's kind of hypothesis generating. Doesn't prove that this diet is healthy, doesn't prove that this diet is going to cause you to have a heart attack next year. But it does mean that you have to look a little bit deeper. So that's why I always kind of go back to what we talked about earlier. It's like it's the root cause, like what's going on with the glycocalyx and the endothelium. If that layer is healthy, maybe you can get away with having these LDL cholesterols of 500 for years. But the second you see that the glycocalyx is damaged and the endothelial dysfunction is happening, and your arteries are stiff and your nitric oxide's low, that person's the time bomb ready to go off in a few years. And you don't want to reduce the Risk of a heart attack. And one year, you want to reduce the heart attack risk for the next 30, 40 years.
- [80:45]
Dr. Gabrielle Laing
You know, you had said something earlier that there's a 20% increase in plaque year over year.
- [80:50]
Dr. Michael Twyman
The calcium score.
- [80:51]
Dr. Gabrielle Laing
The calcium score, Was that the same as those in this keto CTA trial?
- [81:00]
Dr. Michael Twyman
It's kind of apples and oranges because mostly people did not have calcified plaque.
- [81:03]
Dr. Gabrielle Laing
At the beginning because they're too.
- [81:06]
Dr. Michael Twyman
They're young and relatively, quote, healthy.
- [81:09]
Dr. Gabrielle Laing
You know, again, you and I have been friends for quite some time. I want to talk about muscle.
- [81:13]
Dr. Michael Twyman
Excellent.
- [81:14]
Dr. Gabrielle Laing
I want to talk muscle and heart health. I believe that skeletal muscle is the most important muscle and you believe cardiac muscle is the most important muscle. We will probably have to come to some understanding and I am very curious as to the muscle heart connection from your perspective.
- [81:37]
Dr. Michael Twyman
Let's just say that they're synergistic. I don't think one is better than the other. You need both. And that's something that I have say, other than my geriatric training, I didn't learn about a lot in my cardiovascular training. The only people that would talk about it would be the heart failure doctors. Because those patients who were ending up on heart transplant list, they usually were sarcopenic. They're cachexic because their heart is failing. Their body's demanding all the energy resources because being sent to this weakening heart, their skeletal muscles are getting eaten up by all the inflammatory compounds that are coming from a failing heart. So those are the guys that really worried about muscle health.
- [82:13]
Dr. Gabrielle Laing
Do you think it's important to measure VO2 max and grip strength?
- [82:17]
Dr. Michael Twyman
I think both are important. Grip strength is very easy. I check in almost every single patient that comes to my office.
- [82:22]
Dr. Gabrielle Laing
Do you check your own?
- [82:23]
Dr. Michael Twyman
I do.
- [82:23]
Dr. Gabrielle Laing
I'm pretty sure Shane's like, oh, so Shane's my husband if you're a first time listener. And he is a third year urology resident, which is pretty funny. His. I won't say the joke, but anyway, he's always checking his grip strength.
- [82:38]
Dr. Michael Twyman
Where is he at now?
- [82:40]
Dr. Gabrielle Laing
I don't know. Probably superhuman.
- [82:41]
Dr. Michael Twyman
Okay. I mean, he's way more muscular than me, but I'm pretty happy. Like I'm 130 pounds on the right side, 120s on the left side. So I'm top 1% for my age.
- [82:50]
Dr. Gabrielle Laing
Okay. Looking great for 25, friend. Looking great for 25. Do you routinely in our clinic, even though our clinic is largely remote except for my private patients, we don't measure VO2 max. Just a lot of patients they don't want to. They can, but we have people that will measure it for us. I am curious, from a cardiovascular muscle connection standpoint, do you think it's necessary to measure VO2 Max?
- [83:23]
Dr. Michael Twyman
Necessary, probably not. Beneficial, yes, if you're willing to do it. I've done at least two on myself, and they're not fun. I mean, you go. You absolutely feel like you're about to die, and then like, okay, you can stop now. And then at that point when I did it, they're like your average for age. I'm like, great. I'm not trying to be an Olympian. I want to live well. I don't want to be at peak, you know, aerobic capacity all my life. I don't have that much time to train to be an Olympic athlete.
- [83:50]
Dr. Gabrielle Laing
I don't know. You could probably do it.
- [83:51]
Dr. Michael Twyman
I could probably do it if I wanted to. I'll tell you a funny story about when I did a stress test while I was in the fellowship. In a minute. But the VO2 Max, it's a good metric of your aerobic capacity. How well can your mitochondria engines actually work for you? So it's very similar to doing a regular stress test on a treadmill, but you have a mask on that's capturing your expired gases, and they can figure out, like, well, where's your capacity to continually utilize that oxygen? And then where do you hit that threshold? Ballpark, you know? You know, 20 to 40 is kind of like where most people are going to fall. If you're above 40, you're doing something right. If you're under 15 and the cutoff was 14, when I was still doing kind of like hospital work, if your VO2 max was under 14 and you had a bad heart, that was kind of a cutoff, saying like, yeah, we should list you to get you a heart transplant planned.
- [84:40]
Dr. Gabrielle Laing
And you don't routinely. Just to kind of close this out, you don't routinely measure VO2 max.
- [84:45]
Dr. Michael Twyman
If patients are very interested, I will send it for it. I have the Frontier X2 chest strap, which is probably the most sensitive heart strap you can use for exercising. It can measure a EKG while you're exercising, and they claim to be able to kind of relatively accurately measure estimated VO2 max off of that. So I think it's good enough for most people. But if you're really hardcore, got to go do the real thing.
- [85:08]
Dr. Gabrielle Laing
Why don't you think more cardiologists focus.
- [85:12]
Dr. Michael Twyman
On skeletal muscle health because they're focusing on cardiac muscle? The analogy is time Is muscle in the cath lab. When your arteries aren't open, they're rushing to open those arteries up because the muscle cells in the heart are dying until they get their restored blood flow. So at least they use analogy thymus muscle, but they're thinking about cardiac muscle.
- [85:32]
Dr. Gabrielle Laing
If you, you know, you've covered a lot on how to protect your heart. And really, if we were to sum this up, it was lifestyle, be active, sleep. Well, I'm going to fight you on that one. Listen, a lot of parents don't have an option. Get outside, wear blue blocking glasses, maybe eat a diet that augments nitric oxide. Keep your blood pressure low, keep your stress under control. Don't drink alcohol. Caffeine. Okay. Drink alcohol in moderation. Figure out if you are a high or low metabolizers of caffeine. And if you are high, 400 or more is just fine. Just kidding. Check with your doctor. Did I miss anything?
- [86:24]
Dr. Michael Twyman
No. That's an excellent review. And it's the basis of test. Don't guess. Everybody has their own individual story, their individual genetics, and then they go out in the world and do the things they need to do. But some people are at high risk of vascular disease than others. If you do the right testing, you figure out who those people are and which levers you can pull back on to reduce that risk.
- [86:44]
Dr. Gabrielle Laing
If you could pick three tests, you covered the blood test. The blood tests that we talked about were lp, apob, LDL cholesterol, hscrp. Yes. And then also you talked about myeloperoxidase. I will say that in our clinic, almost every woman seems to have higher levels of myeloperoxidase.
- [87:06]
Dr. Michael Twyman
Is there a reason it's associated with autoimmune conditions and women are at higher risk for autoimmune conditions? Highly myeloproxidase can be a marker of HDL dysfunction. So just having high HDL doesn't mean that it's necessary to do anything beneficial to your vascular system. One of the rules of HDL is to go into the arteries, pull out the cholesterol, and take it back to recycle it. But if you have high myeloproxidase, it keeps damaging the HDL and the liver has to keep replacing it. So your HDL numbers are going up in your blood, but they're not actually working. But if you have high myeloproxidase, you got to look and see do they have some type of autoimmune condition or some other chronic infection? Infection that's driving that.
- [87:40]
Dr. Gabrielle Laing
And if they don't, how do you fix that?
- [87:43]
Dr. Michael Twyman
Pomegranate potentially helps.
- [87:44]
Dr. Gabrielle Laing
Okay. You know, I wonder if it's pomegranate or I wonder if it's urlithin A.
- [87:50]
Dr. Michael Twyman
It's probably that.
- [87:51]
Dr. Gabrielle Laing
So for those of you listening, we work a lot with timeline and mitopure. Is this clinically tested, urolithin A, are you taking it?
- [88:00]
Dr. Michael Twyman
Not yet.
- [88:01]
Dr. Gabrielle Laing
Okay, well, I have some, I'll give you some. But I think it's probably. Maybe it's not the pomegranate, but it is, is the. I don't know, I mean we should.
- [88:08]
Dr. Michael Twyman
It's probably a combination.
- [88:09]
Dr. Gabrielle Laing
Yeah. Look into that, the other tests and you know, I'm curious as to what home tests are accurate for looking at heart health.
- [88:18]
Dr. Michael Twyman
It's a great thing that, to kind of look into that because the contents of your blood, it's easy to obtain for most people, but it doesn't tell the whole story. It doesn't tell you what's going on in the arteries. And so, you know. Yes, I have a whole fancy lab of equipment in my office at apollocardiology, which you been to a few times. And we put you through the battery of testing.
- [88:36]
Dr. Gabrielle Laing
I'm due, by the way, aren't I? Or in another year, whenever you want.
- [88:39]
Dr. Michael Twyman
To come, I'm happy to have you back. But in the office, the biggest test that we probably do is the endopath test, which we didn't talk about here today. And that's probably the gold standard way to really test what is your nitric oxide availability and ability for the arteries to dilate. So for those that haven't heard of the test, which most people haven't, the endopath test is a non invasive test. Takes about 15 minutes. You're laying down comfortably. Your fingers have probes on them and they're measuring the flow in your fingers. They do a five minute warm up and there's a five minute period where we have a blood pressure cuff on your arm. Pump it up higher than your systolic blood pressure and the flow cuts off. Your hand goes numb, generally not dangerous. And after five minutes, you open up the stopcock. The blood rushes back down into the arm. This simulates exercise. As the blood rushes back down into the arm, it stimulates the glycocalyx. The glycocalyx says, oh, here comes a bunch of blood. The underlying endothelium releases nitric oxide. The smooth muscle in the artery opens up and the blood rushes back down into your hand. Your hand wakes up and then the test can measure. Well, how much do the arteries dilate with that response? And your artery should at least double in size, but optimally triple or quadruple in size if it's less than 1.68. So your arteries are only dilating 68%. You have what's known as endothelial dysfunction. The arteries can't release nitric oxide on demand. It's kind of like the force field is down. You're more prone that whatever's floating through your blood, the cholesterol particles, the white blood cells, they're more likely to stick to the artery. And you're going to develop plaque in your arteries unless you do something about it. So it's the stress test for the arteries that we do in the office. Now, you can't do that at home yet, but there are tests that you can do that can give you an idea. Is this a problem? And so we talked about it and we got some of the.
- [90:12]
Dr. Gabrielle Laing
Oh, here comes the toys.
- [90:13]
Dr. Michael Twyman
All the toys that.
- [90:14]
Dr. Gabrielle Laing
All right, so for those of you who. Who are listening, not watching, I'll describe them. So let me, let me try them. So I just drank stuff? You're not supposed to drink anything.
- [90:25]
Dr. Michael Twyman
You're supposed to wait at least, you know, 15, 20 minutes.
- [90:27]
Dr. Gabrielle Laing
But, ah, center of the earth is kind of cool. All right, you talk about this. I'm gonna.
- [90:31]
Dr. Michael Twyman
She's gonna play around with the taste.
- [90:32]
Dr. Gabrielle Laing
I'm gonna play around with it. It's okay. This is not gonna be accurate. Yeah, because I just have been drinking.
- [90:37]
Dr. Michael Twyman
So they look like little litmus paper strips. There's a little pad on it that you put saliva. You then bend the tab over. There's a little developer pad on the other side. And if you have nitrites in your salivary pathway, the thing will light up red. If it does, that means you're generally getting a lot of nitrates into your diet and you potentially have good bacteria in your mouth. You have the nitrate reducing bacteria in your mouth to be able to break that stuff down. That ultimately becomes nitrites and nitric oxide. Not everybody has high nitrates in their diet because they're not eating green leafy vegetables. Or they have dysbiosis of the oral microbiome because they're using mouthwash, they're using things with fluoride. And her numbers are really red. So she's getting good nitric oxide through that pathway. So that's step one. I talked about pulse wave velocity. So I'm wearing an Oura ring. The reason I got the Gen 3 was because they did add a feature last year, the cardio age, which is measuring pulse wave velocity. So as the blood rushes past the ring sensors, it's looking at how fast the arteries expand and contract. And you can look at the waveforms and determine how stiff the arteries are. So you want your cardio age to be close to your biological age. Mine is aligned, which is normal.
- [91:48]
Dr. Gabrielle Laing
And this is a pulse ox. It's not.
- [91:50]
Dr. Michael Twyman
This is basically a pulse ox.
- [91:51]
Dr. Gabrielle Laing
Let's see. Turn that sucker on.
- [91:53]
Dr. Michael Twyman
So this one's called the I heart.
- [91:54]
Dr. Gabrielle Laing
So this is a little black box that looks like a pulse ox that I have in my emergency travel kit.
- [92:01]
Dr. Michael Twyman
Correct. So it's going to give you your heart rate and oxygen stats. But I'm not going to pull out my phone right now. But if you had the app running, you do like a 2 1/2 minute run for it, and it will measure the arterial stiffness and will give you a vascular age reading, which can change throughout the day. But generally when I do this, it's usually at my biological age or much younger. If it's higher than biological age. Don't freak out. Like, look at your life.
- [92:23]
Dr. Gabrielle Laing
Go right ahead. Won't do anything. Feel free to do that.
- [92:26]
Dr. Michael Twyman
Figure out why it might be high. Like, oh, I slept two hours last night. I, you know, just did a bunch of nicotine before I jumped on this podcast or something. Whatever. That's probably going to happen.
- [92:35]
Dr. Gabrielle Laing
How bad is nicotine? We have a lot of people that. Let me, Let me see. Wait, let me see the toy.
- [92:39]
Dr. Michael Twyman
Sure, sure.
- [92:40]
Dr. Gabrielle Laing
So we have a lot of friends and people that we know, Matt Producer, who use a lot of nicotine. What does that do?
- [92:47]
Dr. Michael Twyman
It's a vasoconstrictor. And so similar to caffeine, you know, it can cause people to have higher blood pressure and cause palpitations. And so it's once again, like, test, don't guess. Like certain amount of nicotine, maybe it doesn't affect your blood pressure, cause you to have, you know, issues with palpitations. But, you know, if you're going at a person level, a level where it is got to dial it back, you know, and understand, you know, it's a nootropic for some people, you know, it is a cognitive booster, but, you know, but it can also be a vasoconstrictor. So for people who have coronary disease, sometimes it may contribute to them having chest pain with activity.
- [93:22]
Dr. Gabrielle Laing
So everyone is throwing their zins out the window. Matt, he has 6, 6 milligrams. I tried to just Try it. I almost threw up, like, immediately.
- [93:36]
Dr. Michael Twyman
Yeah. And if you're not sensitive. If you're not sensitive to it, or I should say if you're sensitive to it, like, you know, less than a milligram would make most people pretty nauseous.
- [93:43]
Dr. Gabrielle Laing
Oh, it was a terrible idea. And of course, I tried it again. What else do you have in there?
- [93:48]
Dr. Michael Twyman
Next toy. So this is a new one that I'm pretty interested in. This is the Connect QT Pulse. It's a little box that measures blood pressure. So it has a brachial blood pressure cuff. So you'll get your traditional number. It's going to say whatever, 120 over 80, which is a good starting point. But that's the blood pressure just going down to your hand. The thing that this box does that no other one to the market yet does, is it measures central blood pressure. So when I was still an invasive cardiologist, we would feed a catheter into your radial artery or femoral artery and put a pigtail catheter in your aorta, and we can measure your blood pressure in your aorta and then measure the blood pressure in your left ventricle.
- [94:23]
Dr. Gabrielle Laing
Why would someone want that?
- [94:25]
Dr. Michael Twyman
Well, when you're doing a procedure, it's a good idea to know, kind of like how well their heart's working, you know, how hard is the pressure coming out of their heart. Because the higher the pressure in the aorta, the higher the pressure in the coronary arteries, and the more likely that high shear stress could damage the coronary artery. So nobody wants me putting catheters in them just to measure that pressure. But this device can assess what that pressure would be. So the cuff is on your arm, and after it takes the regular measurement, you'll feel it kind of pulsing a little bit. It's basically assessing how stiff the arteries are. Because, for example, if your heart's beating 60 beats a minute, the left ventricle pumps. The blood comes out of the heart, goes down to your legs, and it's going to hit those arteries in your legs, the iliac arteries, and it's going to be a reflection wave. So it's kind of like splashing water at a wall. The water comes back, you can measure how fast that blood is coming back, and that estimates what is the blood pressure that's coming out of your heart. Because that central blood pressure is what the blood pressure that your brain. When you talk about the patients or geriatric and you don't want to infect their central perfusion, it's that central Pressure that you want to focus on, that's the pressure that the coronary arteries, the heart arteries and then also your kidney arteries, that's what they sense. So if your central blood pressure is normal, less than 120 80, but the arm is 150, leave them alone. Their perfusion in the brain is perfect. Don't mess with them. So you want to treat their central blood pressure, you don't want to treat just brachial.
- [95:44]
Dr. Gabrielle Laing
If we were to kind of pause and think about that blood pressure medication, beta blockers, what else? What is first line that you're using?
- [95:54]
Dr. Michael Twyman
Generally, ACE inhibitors, angiotensin receptor blockers or calcium channel blocks blockers are first line beta blockers. Interesting. Particularly the older ones, they lower brachial blood pressure, but they have no effect on that central blood pressure. So you're not really getting the benefits. But the ACE inhibitors, the angiotensin receptor blockers, calcium channel blockers, they lower both brachial and central.
- [96:13]
Dr. Gabrielle Laing
And what are the main side effects of those drugs?
- [96:16]
Dr. Michael Twyman
It depends which class. But ACE inhibitors, generally it's cough. Angiotensin receptor blockers, not a lot. Sometimes if you get your blood pressure too low, then just get back up in the dose. Calcium channel blockers, generous peripheral swelling in their feet sometimes cause some constipation at higher doses. And the beta blockers classically pretty hard to use, particularly in younger people, particularly people who are very active. You know they're going to block catecholamines, so they're blocking adrenaline being secreted. So it can be useful for people who have a lot of palpitations or performance anxiety. But for blood pressure, they really weren't that potent. And then the person's probably going to have exercise intolerance. Their extremities might be cold, they might have sexual dysfunction in guys, so hard to use. But the newer class of beta blockers like Nebivolol, trade name Bystolic, it does have an effect on blood pressure because it affects the nitric oxide pathways. So it's pretty much the only blood pressure medicine in the beta blocker class that I'll use if we're going to be using it. But it's going to be probably third or fourth line after they've exhausted the angiotensin receptor blockers and calcium channel blockers.
- [97:18]
Dr. Gabrielle Laing
The reason I asked you that question is if someone is just getting a brachial artery blood pressure, which is what would be standard and one an individual is treated off of that, is it true that they might not need it because it's not actually measuring the central blood pressure.
- [97:36]
Dr. Michael Twyman
Correct. And that's sometimes the case is where the person says, like, I'm taking the medicines. You know, I'm getting really lightheaded and dizzy at home. I don't feel good. And you check the blood pressure in their arm in the office, and they're like 125. You're like, well, your pressure's a little bit high. Their central pressure is probably like 100 over 60. And their brain is like, hey, I need a little bit higher perfusion pressure. So maybe you need to back off, let the breaker run a little bit higher. So that's why this device is going to probably be a game changer for many people who are at high risk or just very interested in their vascular health. Because this is kind of like the check engine light going on. When your central pressure start to rise, you have a problem. This device also can measure things that will look at the stiffness of the arteries as well. This is a good kind of add on to somebody who has a calcium score of zero. Great. You have a calcium score of zero. But a calcium score of zero means that you haven't developed hard plaque in arteries yet. But this is going to tell you if your arteries are getting stiff and your central pressures are high, you're more at risk for that. So for those people in that keto CTA trial, this might be an interesting device for them to have. And if you'rebecause I know that going into the trial, they had to have normal blood pressures, which if you see a cardiologist in the real world, everybody has kind of the triumph for it. They got high blood pressure, they got diabetes or pre diabetes, and they got high lipid issues. Nobody just has just lipid issues in the real cardiology practice. But if you have stiff arteries with this type of device, maybe you want to start backing off on that kind of keto diet, because maybe you're making a ton of oxidized LDL that's affecting your arteries.
- [99:03]
Dr. Gabrielle Laing
That's really fascinating. And that's called the Connect Connect qt. Okay, well, we. Hey, guys. We are all trying that immediately.
- [99:11]
Dr. Michael Twyman
Yeah. What I was just gonna say we'll link it.
- [99:15]
Dr. Gabrielle Laing
Oh, okay. Yeah. Okay. Julia said we'll put links to all these devices just to close out. Are there a handful of supplements that are evidence based on not anecdotal, but that have randomized controlled trials and evidence in humans that you think are valuable for heart health?
- [99:36]
Dr. Michael Twyman
The short answer is yes, but it's Not a blanket statement where, like, everybody should take all of these things. You know, you have to look for deficiencies, and you got to look for tolerances of certain ones. But start again with, you know, the glycocalyx and the endothelium. If you can't make nitric oxide, there are products out there that can help with that. There's products that can support the glycocalyx. If the glycocalyx is getting damaged, there are supplements that can help regenerate the glycocalyx. Then there's.
- [100:00]
Dr. Gabrielle Laing
Would that be like a beetroot juice and Neo? You sent me like a Neo 40s, a little tab.
- [100:06]
Dr. Michael Twyman
Yeah, the little tabs. Neo 40. That was initially the product that Dr. Nathan Bryan developed. He now has a competitor that is in his own company called M101, which I often utilize. There's another product called Baskinox from a company. Full disclosure, I speak for them sometimes, but that's it.
- [100:23]
Dr. Gabrielle Laing
Throw them off the podcast.
- [100:24]
Dr. Michael Twyman
It doesn't impact your ability to, like, talk about. Because I often. I'm taking that product myself because I've looked at their research and it works well for me. And I do this testing. My numbers look good, so I'm a pretty good biohacker. I try almost everything on myself first and make sure it works. And then I talk about with my patients. And then, you know, there's things, you know, like CoQ10. CoQ10, you know, may help with people who have, like, muscle symptoms when they're on statins. You know, omega 3s prefer people eat their seafood than supplement. But if they're gonna supplement, you know, generally 2 grams a day on fish oil.
- [100:53]
Dr. Gabrielle Laing
But it's also really hard to get enough Omega 3s.
- [100:56]
Dr. Michael Twyman
It's generally very hard.
- [100:58]
Dr. Gabrielle Laing
The Coq 10, is there a dose and is there a form?
- [101:03]
Dr. Michael Twyman
So generally you want to just target blood levels over three. You know, you can either do ubiquinol or ubiquinone. You know, the ubiquinol should be absorbed a little bit better, but it's more expensive. So I just tell people, like, okay, you know, pick a good brand that your doctor works with, but check blood levels and then whatever dose it takes. So ballpark, you know, if you are deficient, you're going to probably need between 100 and 300 milligrams a day. If you're on a statin or beta blocker, add 100 milligrams per drug that you're on that depletes CoQ 10. Magnesium porn for three to four different rations of the body. So anybody has blood pressure issues, palpitations, coronary disease, sleep issues, or 75% of.
- [101:42]
Dr. Gabrielle Laing
Americans who are deficient in magnesium. Yeah.
- [101:45]
Dr. Michael Twyman
And you know what forms basically not oxide because oxide isn't absorbed from the gut. You know, if you're constipated, take oxide. You know, but if you're not.
- [101:52]
Dr. Gabrielle Laing
But if you have a big event, do not take magnesium oxide. Or if you are going on a plane or any kind of long trip.
- [101:58]
Dr. Michael Twyman
Correct. Because it will work.
- [102:00]
Dr. Gabrielle Laing
Not a deal. Yes.
- [102:02]
Dr. Michael Twyman
Those probably are the big ones that I would say.
- [102:05]
Dr. Gabrielle Laing
Well, thank you so much, Dr. Michael Twyman. You are just a wonderful human, a wonderful doctor. I am so grateful that you are willing to take care of me and our patients and just. You do such a fantastic job. Thank you so much for coming on.
- [102:25]
Dr. Michael Twyman
Thank you.
- [102:26]
Dr. Gabrielle Laing
By listening to this episode, you're already doing what most people never do, thinking about prevention before the problem starts. Most heart attacks are preventable, but only if we look deeper than ldl, only if we challenge outdated norms, and only if we value data diagnostics. If this episode shifted your mindset, send it to someone you care about. Because heart disease doesn't wait. And neither should we. If you haven't already subscribed to the show. Thanks for being here. See you next time.