Hacker News Reader

Hacker News

Comment by brandonb | Hacker News Reader

Full thread

brandonb

Before getting a CAC scan, I'd probably do these tests first:

* ApoB - about 20% of people with normal cholesterol results will have abnormal ApoB, and be at risk of heart disease.

* Lp(a) - the strongest hereditary risk factor for heart disease.

* hs-CRP - inflammation roughly doubles your risk of heart disease

* HbA1c - insulin resistance is a risk factor for just about everything.

* eGFR - estimates the volume of liquid your kidneys can filter, and is an input to the latest heart disease risk models (PREVENT).

Easy to order online: https://www.empirical.health/product/comprehensive-health-pa...

CAC is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.

View on HN

Fascinating how these tests are something that is an option in America with people getting them.

In the UK we have the NHS and, although private healthcare is available, the NHS are gatekeepers with long waiting lists to see the doctor.

In UK culture you are just not going to 'waste NHS time' by asking for the tests that could inform you on what lifestyle choices you might need to make in order to head off chronic non-communicable diseases. You have to get a chronic disease, then the doctor will interpret the test results and not let you know what the numbers are, just what medication to take, optionally with lifestyle changes.

As a consequence, nobody in the UK knows what their cholesterol levels and whatnot are, yet, in the USA, plenty of people know these numbers.

Do healthcare providers actively upsell testing in the USA?

>Do healthcare providers actively upsell testing in the USA?

In my experience, normal doctors do not, but there are a lot of private businesses that make their living selling testing.

Also, consider that despite a lot of people knowing their levels in the US through testing availability, health outcomes are not better. So, we know more, but don't do anything about it. I don't know what's worse.

They are better. Life expectancy at birth in the US is dragged down by myriad societal issues but if you survive to middle age, life expectancy begins climbing to the highest in the world.

Really you just need to look at it by state to see the huge difference. There is almost a 10 year difference between the best and worst states.

I think, politely, this perspective misses the forest for the trees (or maybe the trees for the forest).

Out of the approx. 250 million adult americans, a large cross section do manage their health.

While average outcome might be better in the UK, it's useless to lump the 60% (150 million) of americans who are not obese in with the 40% (100 million) who are obese. And while this is easily the most major, it is just one measure of health.

As an anecdote, I saw just this morning plastic adirondack chairs for sale outside a grocery store, and they had a large sticker on them proclaiming in 4-inch lettering that they are rated for 350 pounds(!). That says something sad about the U.S.

As an aside, I am amazed that chairs can be sold without some redundancy, in case of breakage. 350 pounds is not exceptional these days, that is only 160Kg, which is only 90 Kg more than what I weigh with clothes, cup of tea and plate of food... 80Kg is reasonable for a healthy person and two people should be supportable by the chair.

However, chairs get left outside and they can rot. This can lead to collapse even if a 50Kg person gets on. This can be incredibly dangerous. Hence every chair should have a secondary support structure, in some cases this can be wire under tension, other times it might have to be steel tubing.

There are thousands of chair designs, none of them built for the ultimate eventuality of catastrophic failure.

No. There's a *big* difference between the load limit printed on something and it's true expected failure point. As somebody could be hurt by the chair failing I would expect the real strength to be in the ballpark of 3,000 pounds or even more. Figuring the permissible % of expected yield point is handled by the engineers, normally not by the end users.

Load ratings near the failure point are only done when the failure will not cause a problem, or when the failure is actually a desirable property (breakaway tethers of various types.)

> That says something sad about the U.S.

That a lot of couples like to share the same chair??

And is that really so horrible? I would not own a chair flimsy enough that my wife couldn't sit on my lap when I was sitting in the chair.

I know my cholesterol numbers going back almost twenty years, over something like 15 tests. This is because that first test around 2007 showed my HDL was ridiculously low. So I took steps to modify it, and tested again (and again...) to see how it was progressing.

How can you increase your HDL?

N=1, but: I read that carbs lower HDL, and I was eating a very carb-heavy diet.

So over about two months I switched to an informal low-carb diet. e.g. I stopped drinking milk, I ate Carl's Jr. six-dollar burgers as lettuce wraps for lunch, and sometimes just roast beef and mayo.

Over three months I lost something like 30 pounds, hitting a body fat percentage around 12% -- this wasn't the goal, but FWIW.

My HDL before was 17, after those three months, 25.

Then I added in various forms of exercise and got it up to about 55.

I've since engaged in various diets, and levels of exercise -- although I've never gone back to the original diet where whole meals consisted of a quart of ovaltine. My HDL has never dropped below 40, nor been higher than 65.

In the UK, a cholesterol test is offered free of charge to everyone over the age of 40 by their GP, as well as younger people if they have a BMI over 25 or have a family history of high cholesterol levels or heart problems.

They're also available from most community pharmacies (again free of charge for at-risk patients, but for everyone else it should be about £10 for a simple finger-prick test or £30-50 for a full lipid profile).

That is interesting to know, clearly I never knew. It takes about two months to get an appointment where I live so I am not inclined to get a cholesterol test with no good reason. When I registered a blood pressure test, height and weight was all that was needed. With healthy blood pressure and a BMI of 19.5, I would like to see that full lipid profile. However, if I was in the overweight category, the last thing I would want to see is the lipid profile!

By community pharmacy, does that include a typical Boots the Chemist?

Yep, community pharmacy = anything outside of a hospital or similar setting. So Boots, Superdrug, or your nearest no-name chemist on your local high street.

Upsell? It's never been a matter of discussion. Doctors orders some standard bloodwork every year. HDL and LDL are part of it.

We don't even have the phrase 'bloodwork' in the UK. Also, in the UK, you can go to the doctor regularly for a checkup to never get this 'bloodwork' thing you Americans speak of. I have never had any done myself, all I get is my iron level when I donate blood, and I only ask about that after curiosity.

Healthcare is very different in America and I am not seeing the benefits of yearly 'bloodwork', it must be an upsell so they can get people onto statins and whatnot for life.

Multiple things are much better caught earlier. Off the top of my head:

Catch the elevated A1c before it does any damage, or get diagnosed from a hypoglycemic episode?? (By which point a lot of damage has been done.)

Catch the elevated TSH and supplement before there are any symptoms, or wait until the patient presents with hypothyroid? Note that the patient will have been through a fair amount of blah before the diagnosis is made. And thyroid hormones are very dose sensitive and it's a couple of months to stabilize on a new dose, so bringing the patient back to normal can take quite a while. US approach, my wife's TSH was high, they put her on some thyroid hormone, no symptoms of hypothyroid and no rush to dial in the dose because it's still within the body's ability to compensate and thus causes no problem.

And the subject of this thread, statins. Again, much, much better caught before it does damage.

CAC is the right test for people who already have identified that they have major risk factors such as metabolic syndrome/T2D, high cholesterol, etc. It identifies whether heart disease has already advanced enough that the risk factor has become a risk.

Some of the tests you list (like A1C) are baseline things everyone should get checked every year. Agreed that the others could provide value for those who want to know more about their risk level; however, it’s uncommon for those tests to turn up positives without one of the baselines having already raised at least a yellow flag.

None of the tests you listed will tell you whether you have any soft plaque buildup. They just tell you more about your risk factors. However, there are ultrasound tests that can detect increased blood pressure in major arteries, which IIRC does reflect soft plaque buildup.

Lp(a) is a once in your lifetime test and also not very expensive.

Sometimes free as well. Certain CROs offer free screening: https://cardiometabolicscreening.careaccess.com/en?_gl=1*1du...

The test cost me $35.20 and I found out that I have sky high Lp(a), 218 nmol/L. I already take a statin and my cholesterol is well under control (LDL 83). But as has been pointed out, Lp(a) doesn't respond to statins. I'm getting a calcium score done (probably won't be covered but we'll see).

I'm prescribed a baby aspirin for the Lp(a). The AHA no longer recommends baby aspirin to the general population but 218 takes me out of the general population. The thinking is that Lp(a) clots and baby aspirin counteracts that.

Yeah. I've got that evil gene. Presumably took out my uncle at 55. But I'm much more active and my heart still works properly.

I've had high-ish LDL for ages and diet alone couldn't knock it all the way down.

It's only the CAC score that provided me with peace of mind that I didn't need to reach for statins.

The way I view this is that, if you can get more information, why wouldn't you? Cost of course, and I understand why insurance might not cover the procedure, but anybody of a certain age with any risk factors who is in a position to afford it benefits from doing so.

The problem we’ve found is that when you get more information, you are more likely to find things that look off somewhere, which may have no real bearing on your actual health but definitely can cause you to have a worse quality of life—whether because of stress or subsequent more invasive tests or just the time and energy it costs you.

This is why there are tests which previously were recommended to a wide range of people on a regular basis which are now only recommended in more limited settings. PSA is a good example of this.

The question to ask is, is doing this test likely to improve my life, or not? And while you probably can’t know the answer for a specific test in your specific case without trying, you can often know the probability that it will improve your life based on statistical analysis of other people who have gotten that test and how it went for them.

I have a CAC score of zero (no calcified plaque) and I take both a statin and ezetimibe to lower my LDL and ApoB. I disagree with your assessment that your CAC score along means that I statin wouldn't lower your risk.

No, CAC only tests for end stage calcified plaque which is how your body tries to transform soft plaque. It's soft plaque that first lines your arteries and is capable of rupturing. You might be infested with soft plaque, but if none of it has calcified yet (which can take decades) then you'll have a CAC score of zero.

Using CAC store to gauge risk is like waiting until you have end stage symptoms of any disease before you consider yourself at risk. The ship has already sailed and you should have instead focused on prevention for decades.

The sibling comment is a great example of the misinformation here. They have high cholesterol but a CAC score of zero gave them the peace of mind to not use statins.

I'd add in the LDL subcomponent assay as well -- LDL pattern, particle number, peak size, etc. you can get those and all the ones you mentioned for relatively cheap https://www.walkinlab.com/products/view/cardio-iq-advanced-l...

The latest evidence is that if you have ApoB and Lp(a), then particle sizes don't add any more information. This is the most recent research (published July 2025): https://academic.oup.com/eurheartj/article-abstract/46/27/27...

Given the low side effect rate and limited overall impact, shouldn't the bar for deciding to take statins be near-zero? Like, the articles say if there's a 5% chance of a heart attack in the next 10 years there's no reason to take a statin, but if the statin changes that 5% to 4% (that's speculation on my part) then given the limited side effects it would likely be worth it, right?

I know a number of people who report memory issues since starting statins. They also clearly exhibit memory issues but it's hard as an outsider to pinpoint when they started. Unfortunately, they really do need statins.

I used to work with a cardiologist who joked that "we should just add statins to the water," so you have a point.

The current guidelines for prescribing statins are based on your risk of a major cardiac event in the next 10 years (forecasted using a statistical model). But given that plaque builds up in your arteries over your lifetime, there's a strong argument for using a 30-year or lifelong time horizon.

> the low side effect rate

The rate of serious side effects is quite low (e.g. brain fog), but the reported rate for muscle weakness is non-trivial.

It caused a lot of muscle weakness in the legs for two members of my family. The weakness went away for one of them when they stopped taking it.

Statins often have the side effect of raising blood sugar. So there’s a non-trivial tradeoff for a population that is usually on the edge of metabolic disease.

Anyone know of an equivalent in Europe? Dutch doctors always ignore me and say to come back after I’m dead. (But will happily tell me to take Tylenol)

Switch doctors? Ask on dutch social networks I think? Some stuff will also not be approved/covered.

My cardiologist did all of these except the eGFR. My calcium score was fairly high, but not high enough to be concerning since my cholesterol is controlled and my diet and exercise regime are good now. Until the CAC was done, I had no idea if I had any or not. It's better to deal with cholesterol earlier than I did.

> My cardiologist did all of these except the eGFR

eGFR is typically inferred from serum creatinine (not creatine!), which is part of both a comprehensive and basic metabolic panel (CMP/BMP), which your GP usually orders, along with a CBC, and perhaps an HbA1c.

Saw your link, did your test and here's my feedback.

No "share" or "download" button in the app? Sure, "apps are cool" and all that - but what about folks who want to archive or share their health data? AFAIK literally no provision to share all those nifty biomarkers with my doctor (except many, many screenshots)?

Nowhere in the "how to get blood test" email instructions does it bother to mention a urine sample will also be needed. Kinda useful to know if you should not pee right before heading to the lab.

Unfortunately there is no approved oral medicine to lower Lp(a) that I am aware of. (I mean given a normal LDL.) Statins don't lower it afaik. An oral medicine named muvalaplin is being tested for it.

There are some in trials. I'm part of one by Eli Lily. Lp(a) sucks, is genetic and so far there was no medication.

The best way to get tested may be in conjunction with a trial. This was can potentially enroll.

Oddly enough, there's evidence that saturated fat intake inversely affects Lp(a) levels: https://pmc.ncbi.nlm.nih.gov/articles/PMC10447465/

It doesn't help if LDL gets raised due to the SFAs, as LDL is an independent risk factor.

I was just noting the oddness of Lp(a) responding inversely to SFA intake (the reverse of LDL), which also contradicts the conventional wisdom that Lp(a) isn't amenable to lifestyle interventions.

You could theoretically increase SFA to target Lp(a) while still using lipid-altering drugs to target LDL.

I’ve read that (injection currently, not oral) ‘PCSK9 inhibitors’ may help lower Lp(a) where few other things do today.

https://my.clevelandclinic.org/health/drugs/22550-pcsk9-inhi...

There's a clinical trial for a new drug, lepodisiran, which lowered Lp(a) by 93.9%.

Outside of that, if your Lp(a) is high, then the first strategy would be to choose a lower ApoB target than you would otherwise. (Every Lp(a) particle is also an ApoB/cholesterol particle, but 6x more atherogenic. So by lowering ApoB, you are compensating for the effect of high Lp(a))

Summary of the current research/evidence is here: https://www.empirical.health/blog/lipoprotein-a-blood-test/#...

This guy talks about lowering his own with collagen and vitamin C

https://x.com/gregmushen/status/1917780163242385586

And another guy lowering his with Amla, lysine and vitamin C

https://x.com/gregmushen/status/1924660722786828584

It is nonsense because I have truly taken all four in good daily doses for years, and my value is still high.

Since typical blood tests start at under $10, can you codify the value that the company at that link provides that makes their list price $1,490?

That panel costs $190 (and includes 85 biomarkers).

FWIW, similar bundles I've seen online are priced at $400-$500.

All 85 biomarkers, if purchased separately, would cost a total of $1,490. ApoB, for example, usually costs $60 if done in isolation, Lp(a) is $45, hs-CRP is $65 at Quest, etc. The bundles end up having lower pricing due to volume discounts and being able to amortize some of the cost across biomarkers.

Thanks, that's good information. What is your relationship to the company, if any? I wouldn't ask, but it's common when the answer is "none" to provide that info before anyone asks.

I believe eGFR (via creatinine testing) and sometimes HbA1c (if diabetes screening is ordered) are the only things listed may be part of a routine health check from a common/inexpensive blood test.

Tape on the posters name:

about: Data for good. Co-Founder at Empirical Health (https://empirical.health).

Before: Risk Engineering at Brex

Co-Founder of the company (it's on my profile). Yes, you're right--of the biomarkers listed, only eGFR and HbA1c are standard in a routine health check.

I imagine nothing like this is available in Canada?

Reply on news.ycombinator.com