AMA #2: Why a 'Perfect' LDL Won't Save You--Plaque, Statins & Metabolic Health

AMA #2: Why a 'Perfect' LDL Won't Save You--Plaque, Statins & Metabolic Health

A live, unfiltered Ask Me Anything on preventive cardiology and metabolic health — recorded on about three hours of sleep after a night in the OR, which tends to make me a little more candid than usual. We cover the questions you actually ask: how plaque forms and how to stabilize it, what the "best" diet for cardiovascular health really is (spoiler: it depends on you), statins from every angle, Lp(a) and ApoB, the lean mass hyper-responder phenotype, GLP-1s and dementia risk, coronary CT angiograms and the AI tools reading them, carotid disease and how I think about stenting vs. surgery, and a few honest detours into supplements, what I eat, and why medicine is so much better at rescue than prevention. No oracles here — just an informed guide working the front lines, thinking out loud with a curious, generous audience. Use the chapters below to jump to whatever you came for. ⚠️ Educational content only. This is general information, not personal medical advice. Talk to your own clinician before changing any medication, supplement, or treatment plan. Chapters 0:00 — Welcome + how this AMA works 0:58 — High CAC score but a clean carotid duplex: how can both be true? 3:45 — Cleerly vs. HeartFlow: which AI coronary CT analysis is better? 6:26 — The "best" diet for cardiovascular health (there isn't just one) 10:59 — How to actually find a preventive / metabolic cardiologist 13:08 — Amlodipine, dizziness, and tachycardia after weight loss 14:41 — Do you need an ApoB test if LDL is already low on a PCSK9 inhibitor? 16:26 — The fibrous cap: can you thicken it and stabilize plaque? 18:59 — How does arterial plaque actually form? (Atherosclerosis 101) 23:47 — Beta blockers, AFib, and valve repair: a medication for life? 28:09 — When statins raise Lp(a) but lower ApoB 30:10 — How is familial hypercholesterolemia (FH) diagnosed? 32:20 — Erectile dysfunction and vascular health 33:46 — Statins, the full picture: benefits, side effects, and monitoring 45:23 — Lean Mass Hyper-Responders (LMHR), high LDL, and a clean CT 51:59 — Gene therapy for high cholesterol: promise and unknowns 56:04 — Rosuvastatin every other day vs. daily 57:20 — Best statin for ApoE4 carriers + the obicetrapib (CETP) story 1:00:57 — Easing statin muscle pain: CoQ10, vitamin D, gentler statins 1:02:15 — Is high cholesterol a sign of a liver problem? 1:04:24 — GLP-1s and dementia risk: what the data show 1:09:20 — Can your LDL be too low? 1:12:02 — Longevity influencers and GLP-1s 1:13:23 — Saturated fat and LDL cholesterol 1:15:22 — How often to order coronary CT angiograms — and why AI overlays worry me 1:23:19 — What tests prove your heart is healthy? (Why stress tests miss plaque) 1:28:24 — Citrus bergamot with statins or PCSK9 inhibitors 1:29:55 — Bypass conduits: mammary artery, leg vein, and radial artery 1:30:47 — What supplements I personally take 1:34:13 — What I personally eat 1:37:17 — Weak, rolling veins and difficult blood draws 1:38:12 — Why there's still no screening program for the #1 killer 1:44:42 — Is there a CIMT-style test for the heart? 1:45:43 — Post-COVID and post-vaccine vascular problems 1:48:13 — Can surgeons operate from a CTA, or is an angiogram needed? 1:51:25 — Do we use robots in vascular surgery? 1:54:29 — Carotid stenting vs. endarterectomy (and the CREST-2 results) 2:02:19 — Lp(a) of 295, Repatha, and when new Lp(a) drugs may arrive 2:04:17 — At what degree of carotid narrowing do you intervene? 2:07:01 — Book recommendations (and a preview of "Disconnected") 2:13:46 — Bonus: how much do I trust the gut microbiome science? Resources mentioned Bale-Doneen Method provider directory: https://baledoneen.com/find-a-provider/ "Healthy Heart, Healthy Brain" by Dr. Brad Bale & Amy Doneen: https://amzn.to/4o3GvGv My Lp(a) video series — start with the first explainer on how Lp(a) is measured (mg/dL vs. nmol/L) and the "Lp(a) — what now?" follow-up: https://youtu.be/i761M_-zjJQ?si=7yjVJ46GC60Mk85a https://youtu.be/ZdUxECOqd1o?si=i8DhYKF55lKLSafy My two videos on the lab tests I recommend beyond a standard annual physical (Lp(a), hs-CRP, fasting insulin, HOMA-IR, and more): https://youtu.be/vPw38B9QzjM?si=E1HJqn-bKwOW10Xb https://youtu.be/vwORTxzeEMg?si=CpFnD3-MRJjbw39p Let's keep going If you'd like this to become a monthly feature, say so in the comments — and tell me which questions you want answered next time. Got a bike-tour recommendation? Drop it in the comments! High Quality 3rd-party tested supplements at Fullscript (10% discount): https://us.fullscript.com/welcome/ljohnstonmd/store-start ___________________________ 🧬 About Dr. Lily Johnston    Dr. Johnston is a double board-certified vascular and general surgeon in San Diego, specializing in metabolic and cardiovascular prevention. She’s the founder of CorSight Health and a passionate advocate for reimagining how medicine approaches chronic disease.

The Biggest Walking Mistake I See: PAD Q&A

Peripheral artery disease Q&A — including one of the biggest mistakes people make when trying to “walk off” PAD symptoms. In this video, we break down: • Why erectile dysfunction is actually a sign of vascular disease • What an ankle-brachial index (ABI) actually measures • Normal ABI ranges and what abnormal results can mean • Whether you should have vascular testing done at home or in a certified vascular lab • The difference between artery disease and vein disease (including spider veins and varicose veins) • PAD treatment options — from walking programs to procedures and surgery • Recovery times after PAD interventions • How to use progressive overload with walking so you actually improve over time instead of staying stuck As a vascular surgeon, one of the hardest parts of PAD is that people are often given oversimplified advice: “just walk more.” But how you walk, how you progress, and how you interpret symptoms actually matters. Hopefully this helps make the whole thing a little less confusing — and gives you a framework that’s practical, realistic, and evidence-based. Question: Have you or someone you know ever had an ABI test or been diagnosed with PAD? Sign up for more information on my own practice here: https://corsighthealth.com/ High Quality 3rd-party tested supplements at Fullscript (10% discount): https://us.fullscript.com/welcome/ljohnstonmd/store-start Other tools for optimal health (note these are affiliate links): Home BP Cuff: https://amzn.to/49Cq7rh Sonicare Toothbrush: https://amzn.to/3KllfMS WaterPik: https://amzn.to/4894Xi8 Apple Watch with sleep & HR monitoring: https://amzn.to/3XaUn5d Oura Ring with sleep, cycle, and recovery monitoring: https://amzn.to/4riyhLS Intake Breathing Nasal Support: https://amzn.to/48dfQQ1 Personal Blender: https://amzn.to/4pyNGGl True Nutrition Protein: https://oken.do/q2xzqeqw Glass Meal Prep Containers: https://amzn.to/4ocEPJ2 Sleep Mask: https://amzn.to/48fSJV5 Air Purifier: https://amzn.to/4puzTQZ ___________________________ 🧬 About Dr. Lily Johnston    Dr. Johnston is a double board-certified vascular and general surgeon in San Diego, specializing in metabolic and cardiovascular prevention. She’s the founder of CorSight Health and a passionate advocate for reimagining how medicine approaches chronic disease.

Got APOE4? A Vascular Surgeon’s EXACT Plan to Protect Your Brain

Got APOE4? Here’s the exact prevention strategy I would use to protect my own brain if I carried this gene. In this video, I walk through the major modifiable dementia risk factors identified by the Lancet Commission — and how I would actually approach them in real life as a vascular surgeon specializing in cardiometabolic prevention. We cover: * ApoB, vascular disease, and why “brain health” starts in the arteries * What you can do NOW without any clinical support * Blood pressure, insulin resistance, exercise, sleep, and inflammation * Hearing loss, social isolation, alcohol, smoking, and other overlooked dementia risks * Which interventions matter most * How I prioritize prevention clinically * What people with APOE4 often misunderstand about risk ⏰ Chapters: 0:00 Almost Half of Dementia Cases May Be Preventable 0:24 APOE4 Is Not Fate 0:53 Why a Vascular Surgeon Cares About Dementia 2:05 Meet “Carol”: APOE4, Family History, and Fear 3:11 The Lancet Commission’s 14 Modifiable Risk Factors 5:29 Why APOE4 Carriers Still Have Real Hope 6:48 What You Can Start Doing Without a Prescription 7:08 Exercise: The Biggest Lever for Brain Health 8:49 The 4 Exercise Buckets I Recommend 11:56 How to Eat for an APOE4 Brain 16:49 Why I’d Keep Alcohol Near Zero 19:16 Loneliness, Social Connection, and Dementia Risk 21:29 When to Bring Your Doctor Into the Plan 22:11 Make Your Lipids Boring 24:47 Obicetrapib, pTau217, and New Alzheimer’s Biomarkers 29:58 Blood Pressure and APOE4 Risk 32:06 Sleep, Sleep Apnea, and the Brain’s Cleaning System 33:54 Insulin Resistance Is a Brain Problem 36:54 Hearing Loss and Cognitive Decline 38:39 The Shingles Vaccine Dementia Data 41:23 Bonus: Hormones, Homocysteine, and Dental Health 45:37 Why Supplements Are Part 3 APOE4 is NOT destiny. But it is a signal to get serious earlier, and there's so much you can do TODAY to head in the right direction. Missed Part 1? Check it out here:  https://youtu.be/y8vkJE_Zy7A Sign up for more information on my own practice here: https://corsighthealth.com/ High Quality 3rd-party tested supplements at Fullscript (10% discount): https://us.fullscript.com/welcome/ljohnstonmd/store-start Other tools for optimal health (note these are affiliate links): Home BP Cuff: https://amzn.to/49Cq7rh Sonicare Toothbrush: https://amzn.to/3KllfMS WaterPik: https://amzn.to/4894Xi8 Apple Watch with sleep & HR monitoring: https://amzn.to/3XaUn5d Oura Ring with sleep, cycle, and recovery monitoring: https://amzn.to/4riyhLS Intake Breathing Nasal Support: https://amzn.to/48dfQQ1 Personal Blender: https://amzn.to/4pyNGGl True Nutrition Protein: https://oken.do/q2xzqeqw Glass Meal Prep Containers: https://amzn.to/4ocEPJ2 Sleep Mask: https://amzn.to/48fSJV5 Air Purifier: https://amzn.to/4puzTQZ ___________________________ 🧬 About Dr. Lily Johnston    Dr. Johnston is a double board-certified vascular and general surgeon in San Diego, specializing in metabolic and cardiovascular prevention. She’s the founder of CorSight Health and a passionate advocate for reimagining how medicine approaches chronic disease. Disclaimer: This video is for educational purposes only and does not constitute medical advice or establish a doctor-patient relationship.

Brain Health Q&A: ApoB, APOE2, pTau217 & More

What's the optimal ApoB level to reduce Alzheimer’s risk? Is lifestyle or genetics more important? And what does a pTau217 result actually mean for your brain health? In this Brain Health Q&A, I answer your questions about ApoB, APOE2, dementia prevention, blood-based biomarkers, and what the science actually says right now. Missed the first video? Check it out here: https://youtu.be/y8vkJE_Zy7A Topics include: • How low I think ApoB should ideally be for brain health (and what matters more!) • How to think about lifestyle vs genetic risk like APOE4 • What current guidelines recommend for pTau217 and its limitations • What I’d personally focus on for long-term brain protection (and teasers for our upcoming videos in the series) As a vascular surgeon specializing in cardiometabolic prevention, I spent years treating the downstream consequences of vascular disease after the damage was already done. Brain health is no different. Prevention matters most before symptoms start. The brain is not magically separate from the rest of the body. Blood vessels, inflammation, metabolic health, sleep, exercise, and genetics all interact over decades. So let’s talk about how to think about that risk honestly — and practically. 👇 Drop your questions in the comments for the next Q&A. Sign up for more information on my own practice here: https://corsighthealth.com/ High Quality 3rd-party tested supplements at Fullscript (10% discount): https://us.fullscript.com/welcome/ljohnstonmd/store-start Other tools for optimal health (note these are affiliate links): Home BP Cuff: https://amzn.to/49Cq7rh Sonicare Toothbrush: https://amzn.to/3KllfMS WaterPik: https://amzn.to/4894Xi8 Apple Watch with sleep & HR monitoring: https://amzn.to/3XaUn5d Oura Ring with sleep, cycle, and recovery monitoring: https://amzn.to/4riyhLS Intake Breathing Nasal Support: https://amzn.to/48dfQQ1 Personal Blender: https://amzn.to/4pyNGGl True Nutrition Protein: https://oken.do/q2xzqeqw Glass Meal Prep Containers: https://amzn.to/4ocEPJ2 Sleep Mask: https://amzn.to/48fSJV5 Air Purifier: https://amzn.to/4puzTQZ ___________________________ 🧬 About Dr. Lily Johnston    Dr. Johnston is a double board-certified vascular and general surgeon in San Diego, specializing in metabolic and cardiovascular prevention. She’s the founder of CorSight Health and a passionate advocate for reimagining how medicine approaches chronic disease.    #MetabolicHealth #CardiovascularPrevention #HeartHealth #Longevity #InsulinResistance #DrLilyJohnston #DrLily #WomenInMedicine #Surgeon #VascularSurgeon #PreventiveMedicine #PADPrevention #HeartAttackRisks #HealthPortfolio #California #SanDiego #Arizona #Virginia #Minnesota

Half of Alzheimer's Patients Carry APOE4 - You Don't Have to Be One of Them

If you've been told APOE4 means you're destined for Alzheimer's, the science says something very different. As a vascular surgeon who has spent years treating the end-stages of preventable disease, I want to give you a clearer picture of what APOE4 actually does, and what it doesn't. In this video, I break down: - What the APOE4 gene is and how it affects your brain - Why it raises Alzheimer's risk — but doesn't guarantee it - The surprising evolutionary reason APOE4 exists in the first place - What the science actually says about Alzheimer's prevention if you carry the allele APOE4 is the most significant genetic risk factor for late-onset Alzheimer's. But risk is not destiny. Understanding the biology gives you real options — and that's exactly what this channel is about. 🔔 Subscribe for evidence-based prevention medicine — straight from the OR to your screen. 📩 Questions? Leave them below — I read everything. I advise you to go through your clinician for testing. But if you want to do it on your own, you can order it here: https://www.ultalabtests.com/partners/lilyjohnstonmd/test/cardio-iq-apoe-genotype-test Chapters: 0:00 APOE4 is not fate 0:24 What ApoE does in the brain 1:54 ApoE2, ApoE3, and ApoE4 explained 3:22 How APOE4 became linked to Alzheimer’s 4:23 How much APOE4 raises risk 5:37 Why APOE4 does not guarantee Alzheimer’s 6:50 What APOE4 is actually doing 9:46 Amyloid, lipid trafficking, and brain fuel 11:07 Why does APOE4 still exist? 11:29 APOE4 is the original gene 14:51 APOE4 as an immune-modulator gene 17:05 Ancient immune system, modern environment 19:03 The blood-brain barrier feedback loop 20:02 Same gene, different environment 21:36 The gene is fixed, but the provocation isn’t 22:55 What we’ll cover in Part 2 23:40 Should you test for APOE4? 25:04 Knowing turns fate into a head start This content is for educational purposes only and does not constitute medical advice. Always consult your physician. Sign up for more information on my own practice here: https://corsighthealth.com/ High Quality 3rd-party tested supplements at Fullscript (10% discount): https://us.fullscript.com/welcome/ljohnstonmd/store-start Other tools for optimal health (note these are affiliate links): Home BP Cuff: https://amzn.to/49Cq7rh Sonicare Toothbrush: https://amzn.to/3KllfMS WaterPik: https://amzn.to/4894Xi8 Apple Watch with sleep & HR monitoring: https://amzn.to/3XaUn5d Oura Ring with sleep, cycle, and recovery monitoring: https://amzn.to/4riyhLS Intake Breathing Nasal Support: https://amzn.to/48dfQQ1 Personal Blender: https://amzn.to/4pyNGGl True Nutrition Protein: https://oken.do/q2xzqeqw Glass Meal Prep Containers: https://amzn.to/4ocEPJ2 Sleep Mask: https://amzn.to/48fSJV5 Air Purifier: https://amzn.to/4puzTQZ ___________________________ 🧬 About Dr. Lily Johnston    Dr. Johnston is a double board-certified vascular and general surgeon in San Diego, specializing in metabolic and cardiovascular prevention. She’s the founder of CorSight Health and a passionate advocate for reimagining how medicine approaches chronic disease.    #MetabolicHealth #CardiovascularPrevention #HeartHealth #Longevity #InsulinResistance #DrLilyJohnston #DrLily #WomenInMedicine #Surgeon #VascularSurgeon #PreventiveMedicine #PADPrevention #HeartAttackRisks #HealthPortfolio #California #SanDiego #Arizona #Virginia #Minnesota