Watch the full episode & view show notes here: http://bit.ly/3YSMOOX Become a member to receive exclusive content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ In this episode, Ethan Weiss, preventative cardiologist at UCSF, compares & contrasts the diagnostic imaging tools, CAC (coronary artery calcium score) & CTA (CT angiography), used to image plaque & how these tools inform our understanding of ASCVD risk & guide clinical decision-making. He discusses the types of plaque that cause events & the data that make a case for optimal medical therapy over stenting outside of particular cases. He explains why high blood pressure is problematic & walks through the data from clinical trials testing aggressive treatment. He talks about the best way to measure blood pressure, why we shouldn’t simply accept that blood pressure rises with age, & how he uses different drugs to treat hypertension. Additionally, he explains our current, but limited, understanding of the role of metabolic health in ASCVD. He discusses the impact of fat storage capacity/location & explains how & why there is still a residual risk, even in people who have normal lipids and blood pressure. We discuss: 0:00:00 - Intro 0:00:08 - Ethan’s entrepreneurial work in the cardiometabolic disease space 0:02:03 - Calcium scans (CAC scores) & CT angiography (CTA), & how it informs us about ASCVD risk 0:07:15 - Peter’s historical CAC scores, CTA results, & how one can be misled 0:12:07 - How Peter’s CTA results prompted him to lower his apoB 0:19:39 - Calcium scans vs. CT angiogram (CTA) 0:28:07 - How Ethan makes clinical decisions based on CTA results & plaque burden, & the importance of starting treatment early to prevent ASCVD 0:34:12 - Improved methods of CTA to grade plaque lesions & how it’s shaped medical decisions such as stenting 0:43:31 - Why Ethan favors optimal medical therapy over stenting outside of particular situations 0:57:23 - The need for FFR CTA, & the potential for medical therapy to eliminate ASCVD 1:01:31 - The fat attenuation index (FAI) & other ways to measure inflammation in a plaque 1:04:00 - Statins & exercise may increase the risk of calcification, but what does this mean for risk? 1:10:54 - The root cause of statin hesitation 1:17:07 - Importance of keeping blood pressure in check, defining what’s normal, & whether we should just accept higher blood pressure with age 1:28:59 - Blood pressure variability, how to best measure it, & data suggesting the enormous impact of keeping blood pressure down 1:45:05 - Drugs for treating high blood pressure recommended by the ALLHAT trial 1:48:27 - What the SPRINT trial says about the aggressive treatment of hypertension, & the risks of such treatment 1:54:04 - Confirmatory results in the STEP trial for blood pressure, & how Ethan uses the various drugs to lower blood pressure in patients 2:03:06 - The role metabolic health in ASCVD 2:08:50 - The impact of fat storage capacity & location on metabolic health & CAD -------- About: The Peter Attia Drive is a weekly, ultra-deep-dive podcast focusing on maximizing health, longevity, critical thinking…& a few other things. With over 45 million episodes downloaded, it features topics including fasting, ketosis, Alzheimer’s disease, cancer, mental health, & much more. Peter is a physician focusing on the applied science of longevity. His practice deals extensively with nutritional interventions, exercise physiology, sleep physiology, emotional & mental health, & pharmacology to increase lifespan (delay the onset of chronic disease), while simultaneously improving healthspan (quality of life). Learn more: https://peterattiamd.com Connect with Peter on: Facebook: http://bit.ly/PeterAttiaMDFB Twitter: http://bit.ly/PeterAttiaMDTW Instagram: http://bit.ly/PeterAttiaMDIG Subscribe to The Drive: Apple Podcast: http://bit.ly/TheDriveApplePodcasts Overcast: http://bit.ly/TheDriveOvercast Spotify: http://bit.ly/TheDriveSpotify Google Podcasts: http://bit.ly/TheDriveGoogle Disclaimer: This podcast is for general informational purposes only & does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information & the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have, & they should seek the assistance of their healthcare professionals for any such conditions. I take conflicts of interest very seriously. For all of my disclosures & the companies I invest in or advise, please visit my website where I keep an up-to-date & active list of such companies.