Brent's Latest Heart Procedure

Brent: People ask me, "Aren't you glad that you know?" And I think that I am. But you don't really know whether or not you're happy about it until you've completed the procedure and not died. You've had this thing your whole life and didn't know that you had it. We go in and do this procedure and realize, "Hey, you're fine, your heart's fine."

Brent: The way it is. "But sorry we killed you in the procedure." I'd be very—you know—my family, I guess, would be...

Todd: Would be.

Brent: Annoyed. Very unhappy about that.

Todd: That's right. Yeah.

Brent: Welcome to Death Clock. I'm your host, Brent Franson. Today we speak with my personal doctor, Dr. Todd Dorfman. He's a private doctor or concierge doctor. We talk about how I got connected to him, and we go deep into my health. I had shared earlier on the show that I had a CT scan because of high cholesterol, and I found out that I have an anomalous coronary artery and was considering open heart surgery.

Brent: We talk about the outcome of the diagnostics associated with that, and then we go into how I might think about medications for treating my high cholesterol and avoiding Alzheimer's. The goal here is not to just talk about myself, but to use myself as a guinea pig and share the journey that I'm going through with my doctor here in case it's helpful for others.

Brent: Dr. Dorfman is a really wonderful doc and a wonderful guest. I hope you enjoy.

Brent: Dr. Todd Dorfman, welcome back to the show.

Todd: Thanks, Brent. Thanks for having me.

Brent: So this is one of those episodes that's going to be all about my health. There's an update on something we've discussed in the past related to a procedure that I had. Then we'll jump into how you, as my private doctor or concierge doc, are thinking about my preventative health.

Brent: And in case that's helpful for others, that's the background. Let me give the actual story of how we met because it's a good segue into what we're going to talk about first. For Death Clock, I input all of my data and it recommended a CT scan—a coronary CT angiography.

Brent: I had done a CT scan to get a calcium score, which was zero, but I wasn't aware of this type of CT scan. What it is, is you put an IV into your arm with dye that goes into your blood, and it's basically a 3D X-ray of your heart that shows plaque buildup or lack thereof, in my case.

Brent: The reason it's different from a basic CT scan is it shows four different types of plaque, whereas a standard scan only shows calcified plaque in the heart: two types of hard plaque (one calcified) and two types of soft plaque. Calcified plaque is actually the least concerning of the four types.

Brent: I said, "What is this CT scan? I've got to drink the Kool-Aid here of what Death Clock is recommending." I did some research, and you, Dr. Todd Dorfman, were one of the names that popped up on a list of concierge docs who refer patients for these CT scans.

Brent: I reached out to you, and the rest is history. I did the CT scan, you ended up becoming my doc, and you joined the clinical board at Death Clock. So that's how we met. To continue with the context, you referred me to get the CT scan, and I went and got it.

Brent: Despite the fact that I have a lot of cardiovascular risk in terms of my biomarkers—my ApoB and LDL are both very high, though I don't have high Lp(a), which would indicate genetic risk—I don't have any plaque in my arteries.

Brent: That's a very important distinction because plaque in the arteries is how you know whether someone actually has heart disease. High cholesterol in and of itself is not heart disease, though it is highly correlated. However, the scan found that I have an anomalous right coronary artery. We all have a right coronary artery and a left coronary artery.

Brent: My right coronary artery originates on the left side. Because it starts where it shouldn't and takes a path it shouldn't, it goes between the pulmonary artery and the aorta. That means I might be at a much higher risk than average for sudden death while exercising. This is an incidental finding that pops up in a number of cases.

Brent: We had to figure out what to do. You and I spent some time together, talked to some cardiologists, and realized we had to determine whether or not to have open heart surgery. If you're at a really high risk of dying from this anomalous right coronary artery while exercising—exclusively while exercising, with no risk at rest—

Brent: Well, let's figure out if we need to saw the breastbone in half, open up, and fix this thing.

Todd: Yes.

Brent: You don't want to do that if you don't have to, but I also don't want to die of an anomalous right coronary artery. One thing led to another, and I ended up at the Cleveland Clinic. Since you and I are in Colorado, they recommended Cleveland Clinic, where they do a heart catheterization. Basically, they thread a wire into your heart.

Brent: I'm oversimplifying here, but that allows them to look at a number of risk factors to figure out how likely it is that I'm going to die. Heart caths are very common for things like stents, but in this case, there's an anomalous coronary group at Cleveland that does a cath very specific to anomalous coronary arteries.

Brent: What they do is thread a wire through the anomalous artery to get a sense of how wide it is and measure a whole bunch of parameters to see how risky it is.

Brent: I wanted to start the conversation with you because I think this is a really interesting example of how complicated medicine and diagnostics are. We talk about this with full body scans: why wouldn't I want a full body scan to see if anything is happening? Well, if we identify something, it's not always clear what it is.

Brent: There can be risk in these diagnostics. To finish my lead-up: basically, you can enter through the wrist via the radial artery, or through the femoral artery in the groin. For some reason, I really didn't want to go through the femoral artery.

Brent: I had wrapped my head around using the wrist artery, and then they said, "Hey, we're going through the femoral." I just had to come to terms with that.

Todd: What are you going to do?

Brent: Yeah, what are you going to do? You're there, shaved, hooked up to multiple IVs, and about to sign the paperwork right before getting wheeled into the OR. I was in Cleveland, alone, and my wife was very pregnant. I'm thinking, "What am I doing in Cleveland?" Then right before I sign, they say, "When we do these heart caths, there is a 1 in 1,000 chance of stroke or death."

Brent: I thought 1 in 1,000 wasn't too bad. But then they added, "In this case, when we stick the wire through the anomalous right coronary artery, there's a 1 in 100 chance of stroke or death." That might sound low, but almost nothing we do in daily life carries a 1 in 100 chance of stroke or death.

Brent: To put it in perspective, skydiving risk is 1 in 500,000. So I was putting myself at very high risk, and I don't have anywhere near a 1 in 100 daily risk of dying from the condition we were trying to evaluate. The net result was that it didn't seem like I needed the surgery.

Brent: We'll get to that, but how do you think about that as a clinician and my doctor? I don't think we knew about the 1 in 100 risk beforehand—that wasn't a number we had discussed. That's the same risk as open heart surgery, so these decisions are very tricky.

Brent: So with that lead-up, how do you think about that kind of diagnostic procedure in a case like mine? How did you evaluate the risk for a patient like me?

Todd: Obviously, it's a complex and interesting problem—though in medicine, "interesting" is never a great word for the patient. Putting myself in your shoes, it's a scary proposition: "Am I going to get a saw through my breastbone, or am I going to walk around thinking I might drop dead every time I exercise?"

Todd: How do we reconcile this? There's a difference between an incidental finding on one of these tests and a false positive. Sometimes with cancer screening tests or CT coronary angiography, we might see something that turns out to be nothing—a figment of radiological imagination. In your case, this was a real finding that we had to address.

Todd: In a way, finding it was a very positive thing. I spoke to a patient earlier this week who reminded me of a similar case: nearly a decade ago, we were preparing a guy for a hip replacement, and while trying to figure out what was going on with his hip, I ordered a CT scan.

Todd: Incidentally, we found a rare tumor in his appendix and removed it; he's now at his ten-year anniversary. Sometimes incidental findings are really important, and yours was. The critical question was: when you exercise, is blood flow to your heart going to clamp off and cause sudden cardiac death from a fatal rhythm?

Todd: That's what we were up against. As a clinician, the first thing I thought was that your exercise history throughout your life has been fairly aggressive and extreme at times. You've "tested the waters," so to speak, in terms of exertion—if you were going to have a severe rhythm issue, you probably would have experienced one already.

Todd: Then it came to light that while you were running in a very warm environment—in the Grand Canyon or Death Valley—you experienced a rhythm disturbance. Dr. Doucette and I wondered if that disturbance was an inkling that something was going on.

Todd: We concluded that we needed to do more testing to be safe. There are very few documented cases of this specific anomaly worldwide, which means we don't have extensive data on the long-term risks.

Todd: The Cleveland Clinic has the Anomalous Heart Group, which is pretty much the world standard for figuring out who needs a corrective procedure and who can safely continue their normal activities. As they did with you, they went in through the groin with a heart catheterization.

Todd: They administered dobutamine and atropine, which are two medications that simulate the effects of stress on your heart.

Brent: They gave me fentanyl as well, which kept me relaxed since I was awake for the procedure. But yes, they sped up my heart rate.

Todd: Right. They gave you medication to keep you calm while awake. The atropine and dobutamine mimic the stress on your heart as if you were running up a mountain.

Todd: Your heart rate went up considerably. Those medicines increase your heart rate, pumping power, and oxygen demand. At the same time, they used IVUS (intravascular ultrasound) to examine the shape and structure of the anomalous vessel.

Todd: Based on the flow characteristics at rest versus under medication-induced stress—where your heart rate was sustained around 160—they determined you didn't have enough of a flow deficit to warrant a surgical procedure. You weren't experiencing enough hemodynamic change to justify it.

And that's where the Cleveland Clinic piece ended.

Brent: When the heart speeds up, it isn't compressing the artery enough to block blood flow, so I'm not at risk. It really illustrates the overall complexity of medicine. Although this was an incidental finding of a real issue—rather than a false positive or a dark spot on a full body scan—it required careful evaluation.

Brent: People ask me, "Aren't you glad that you know?" I think I am, but you don't really know whether you're happy about finding out until you complete the testing and survive it. If I had been the 1 in 100 case who died during the diagnostic procedure, the outcome would have been tragic.

Brent: You have this condition your whole life without knowing it, you incidentally discover it on a scan looking for plaque, you undergo a procedure, and you learn your heart is fine as is.

Brent: If a procedure killed you just to tell you that, your family would be extremely upset.

Todd: Would be.

Brent: Annoyed and very unhappy about that.

Todd: Right. That's right. Yeah.

Brent: In an alternate universe, you decide not to take the risk of the procedure, and then months or years later you drop dead while trail running because you didn't evaluate it. It's hard to evaluate until you go through the process and come out okay.

Brent: I feel really good about it now, but that's easy for me to say because I was one of the 99 out of 100. It speaks to the complexity of human physiology, modern medicine, and diagnostics. It's not just about identifying a condition; there is inherent risk in the diagnostic process itself.

Brent: That has never been clearer to me than through this experience.

Todd: I wholly agree. You make these choices based on risk versus benefit. In this case, we don't have a lot of standardized data. Some decisions are crystal clear—like removing a specific adrenal tumor where outcomes are well documented. But for this condition...

Todd: The only other case I've managed was a 13-year-old runner participating in the Bolder Boulder who had a similar anomaly.

Brent: That's a 10K race here in Boulder.

Todd: He suffered sudden cardiac arrest at the finish line. We were right there and successfully resuscitated him, but that incident revealed his anomalous coronary artery. It was the most intense physical exertion he had ever experienced.

Todd: He essentially died and was brought back. Unfortunately, that is how many of these anomalies are discovered. We don't have a large pool of active people like you who discover it incidentally, because relatively few people get preventative heart scans.

Todd: Checking for plaque is part of my practice, but finding this was incidental. You were in a small cohort without extensive medical guidelines, so we relied on expert opinions, clinical judgment, and shared decision-making between you, the cardiologists, and me.

Brent: It's frightening as a parent to realize that many of these issues are only discovered post-mortem in teenagers. You witnessed a 13-year-old suffer cardiac arrest right in front of you at a race.

Brent: Your team resuscitated him, and he went on to have corrective surgery and is doing great today.

Todd: That's right. But imagine if he had been playing in the backyard with friends instead. We were operating a full medical unit for a race of 50,000 people because we anticipate cardiac events and are fully prepared for them.

Todd: If he had been on a casual bike ride, this likely would have been an autopsy finding.

Brent: That's a wild story. Another clear lesson for me came from talking to a cardiologist—not a surgeon, but a respected specialist I reached out to independently before a trip to Montana with friends.

Brent: We were planning strenuous physical activities. This was after I learned about the anomalous artery, but before I knew I didn't need surgery. On my way to the airport, his advice was: "Cancel the trip and get operated on immediately. You have a mechanical problem with a mechanical solution."

Brent: But before I learned I didn't need the surgery, I didn't really understand the risk. And his perspective. I'm on the way to the airport was, don't I don't go on this trip and be, you should just cut immediately. This is you've got a mechanical problem. There's a mechanical solution. Let's cut you open and get it done, basically.

Brent: Without a second opinion or access to Cleveland, someone could easily undergo unnecessary heart surgery. Open-heart surgery carries major risks, including a 1 in 100 mortality rate.

Brent: Even in the best-case scenario, recovery is difficult. They saw your breastbone in half, leaving you sidelined for a month and taking up to a year to reach 100%. It would be easy to trust a single authority figure and agree to an unneeded operation.

Brent: You want to protect your life for your family, so you move forward with it. How significant is that risk in medicine, and how do you view it?

Todd: It's significant and unfortunate. Even with surgery, we lack comprehensive outcome data proving you would be definitively safer long-term. Theoretically, unroofing the artery improves blood flow like unkinking a hose, but the statistical proof isn't fully established.

Todd: Unfortunately, this scenario happens often. We spoke with a local cardiothoracic surgeon who took the same stance, saying, "You just need to get this done."

Todd: When you're a surgeon, every problem looks like a surgical solution. Surgeons were traditionally taught to unroof or liberate anomalous arteries whenever detected.

Todd: Recent literature has evolved significantly. That's why the Cleveland Clinic team developed specialized protocols to evaluate who is truly at high risk. Their surgical team is highly specialized, with only two surgeons performing that specific procedure.

Todd: Without access to a specialized group or a doctor willing to seek additional opinions, a patient might undergo surgery that offers little to no benefit.

Brent: Or one that I didn't need in the first place.

Todd: Exactly. It's a critical distinction.

Brent: There are no built-in system checks in medicine that automatically stop an unnecessary procedure. If one surgeon advises surgery and the patient consents, it happens. It's easy to see how someone could end up receiving invasive treatment unnecessarily.

Brent: If the doctor, in his or her judgment is thinks it's necessary to do it and you as the patient say, okay, I'm going to do it, then you know, those surgeries can happen unnecessarily. I mean, there's definitely some alternate universe where that's the path I go down and I get this very extreme surgery that I don't need in the first place.

Todd: Connecting with Cleveland Clinic came through professional networking. A colleague at Denver Health had a patient with the exact same anomaly and connected me with the specialist in Cleveland.

Todd: It was about recognizing that immediate surgery might not be the best path and weighing the surgical risks against the fact that you've exercised for over 40 years without incident.

Todd: Fortunately, it worked out, but finding clarity often requires extensive investigation.

Brent: It highlights the importance of getting second opinions and multiple perspectives. The first specialist I consulted was highly experienced and well-regarded, so it would have been easy to accept his recommendation at face value.

Brent: I'm grateful for your guidance in navigating the process and getting me to Cleveland. I was having nightmares thinking about a bone saw.

Todd: I know.

Brent: I had mentally prepared myself for open-heart surgery, telling myself I'd do it ten times over to be there for my kids, but it certainly wouldn't have been easy.

Todd: I try to put myself in the patient's shoes and treat them like family. It was a difficult situation because the alternative choice would have been restricting physical activity dramatically.

Todd: That introduces major healthspan and longevity trade-offs. You could choose a sedentary lifestyle to stay safe, but that carries its own risks.

Brent: I want to stay active, and exercise is essential to me. Transitioning to broader cardiovascular health: I feel like I'm entering the medication phase of my longevity journey.

Brent: I've completed my screenings: Cologuard was negative for colon cancer risk, skin checks were clear, and while my biomarkers indicate risk for heart disease, I have zero arterial plaque.

Brent: We addressed the anomalous right coronary artery, and I've done full-body scans and microbiome testing. Genetic testing shows I am a single-allele ApoE4 carrier, placing me at an increased risk for Alzheimer's and dementia. I also have high cholesterol and high ApoB.

Brent: My HbA1c—a key metabolic marker—is right on the boundary between normal and pre-diabetic. The Death Clock AI indicates my primary long-term concern is Alzheimer's risk, recommending aggressive management.

Brent: Options include statins, PCSK9 inhibitors, or possibly GLP-1 agonists. There's also research suggesting low-dose Cialis could offer cardiovascular benefits. How do you evaluate my profile—high cholesterol, ApoE4 carrier, but zero plaque?

Brent: My blood pressure runs slightly high, around 135/80, even on Losartan. How should we view statins in this context?

Todd: The core topic here is cognitive decline. People often equate cognitive decline exclusively with Alzheimer's disease, assuming they are identical.

Todd: Cognitive decline is an umbrella term encompassing several conditions. Alzheimer's is specifically characterized by tau tangles and amyloid plaques. Regarding statins and preventative strategies...

Todd: A key priority is managing vascular health to prevent clogged blood vessels in the brain. Fortunately, your risk for severe vascular disease appears low given your clean heart scans.

Todd: You don't have vascular disease in your carotid arteries or aorta. That said, studies on statins for individuals at elevated risk of cognitive decline are quite favorable. Statins have been shown to reduce cognitive decline risk, even in patients without severe hyperlipidemia.

Todd: Certain statins are lipophilic while others are hydrophilic. Lipophilic statins cross the blood-brain barrier, whereas hydrophilic ones do not. Depending on our primary goal, we can select the appropriate statin type.

Todd: Evidence-based strategies for mitigating cognitive decline include physical activity, cardiometabolic management, statins, low-dose lithium, and emerging targeted therapies.

Todd: Optimizing your metabolic and cardiovascular health remains the single best path to protect against vascular disease progression.

Brent: What's good for the heart is good for the brain. For someone with high cholesterol, elevated ApoB (around 130), and an ApoE4 allele, aggressive prevention would target an ApoB level below 60. Diet and lifestyle alone likely won't achieve that target.

Brent: Does starting a statin make sense for a 43-year-old male with this profile to aggressively lower ApoB?

Brent: Is driving down ApoB the best approach?

Todd: It's a nuanced clinical question. For context, individuals with an ApoE 3/3 combination have a 10% to 15% baseline risk of developing Alzheimer's by age 85.

Todd: An ApoE 4/4 genotype carries around a 50% risk. An ApoE 3/4 genotype, like yours, lands in the middle—roughly 20% to 30% risk depending on the study.

Todd: Standard statin recommendations stem from populations with documented vascular dementia, arterial blockages, or prior strokes. Patients with zero coronary plaque alongside elevated cholesterol aren't well represented in classic trials.

Todd: However, the potential benefits far outweigh the risks. The side effect profile of low-dose statins is exceptionally low, while providing broader protective benefits against cardiovascular events.

Todd: It supports general longevity and vascular health, making it a prudent intervention in your case.

Brent: To summarize: ApoE status (whether 3/3, 2/3, 3/4, or 4/4) is easily checked via a standard blood or genetic test. While there isn't a targeted trial specifically for 40-somethings with zero plaque taking statins purely for prevention...

Brent: The broader safety and efficacy data for statins are robust. Given the low risk of side effects, the risk-reward ratio strongly favors treatment.

Brent: Aside from minor initial adjustments like mild GI upset, statins are very well tolerated long-term.

Brent: Starting a low-dose statin and monitoring my biomarkers makes good sense.

Todd: It's a logical approach. Utilizing a medication class with decades of established safety data is a smart way to hedge our bets against elevated ApoE4 risk.

Brent: What about adding a low-dose GLP-1 agonist, like Ozempic or Wegovy? Beyond weight management, GLP-1s lower systemic inflammation and support cardiovascular health, though recent trial data showed mixed results regarding Alzheimer's risk specifically.

Brent: Recent studies failed to demonstrate a direct reduction in Alzheimer's incidence. How do you view GLP-1 medications for someone in my situation?

Todd: GLP-1 stands for glucagon-like peptide-1, an incretin hormone naturally secreted in response to food intake.

Todd: Anticipating or smelling food triggers GLP-1 release, which stimulates insulin secretion to manage incoming nutrients.

Todd: GLP-1 suppresses glucagon—which normally signals the liver to release glucose—allowing insulin to clear glucose into cells. It also delays gastric emptying, promoting satiety.

Todd: GLP-1 receptors are expressed throughout the body—including the pancreas, brain, and stomach—mediating various physiological effects. They offer significant cardiovascular protection.

Todd: They protect renal function and carry FDA approvals for secondary prevention of heart attacks and strokes in high-risk patients, alongside indications for type 2 diabetes, obesity, and obstructive sleep apnea.

Todd: Looking at the bigger picture regarding ApoE4: optimizing cardiometabolic health is essential for preserving cognitive function, and GLP-1 agonists are exceptionally effective tools for cardiometabolic optimization.

Todd: I recently spoke with an 80-year-old patient with prior cardiac interventions who lost nearly 50 pounds on a GLP-1 agonist.

Todd: His HbA1c dropped from 6.8% down to 5.3%, restoring normal glycemic control and significantly improving his quality of life.

Todd: While trials targeting amyloid/tau accumulation yielded mixed results, GLP-1 therapy remains highly valuable for preventing vascular and metabolically driven cognitive decline.

Brent: So combining a low-dose statin with a low-dose GLP-1 agonist represents a reasonable preventative strategy for my health profile, even without significant vascular disease or obesity.

Todd: Given your clean vascular scans, we are taking proactive steps to preserve optimal function rather than treating established disease. However, it remains a sound strategy for long-term risk reduction.

Todd: Using GLP-1 therapy as a preventative measure against cognitive decline is a legitimate clinical option.

Brent: GLP-1 agonists also appear to facilitate behavioral change by quiet food-related thoughts and reducing cravings, making lifestyle choices much easier to maintain consistently.

Brent: Relying solely on willpower and lifestyle interventions often produces inconsistent long-term results, even with strong professional support.

Brent: Many people struggle with habits in an environment full of addictive triggers. While I've successfully quit smoking and cannabis, alcohol remains a subtle challenge.

Brent: My drinking is relatively infrequent—maybe 5 or 6 times a month, usually capping at 3 or 4 drinks—but the mental impulse ("beer noise") recurs frequently in the late afternoon.

Brent: Even though I usually resist the urge, occasionally I give in, which disrupts my sleep. GLP-1 agonists might help quiet those background cravings as well.

Brent: Eliminating that subtle mental friction would be valuable, even if my alcohol use is moderate overall.

Brent: Emerging evidence suggests GLP-1 medications can effectively blunt alcohol cravings.

Todd: Having directed an addiction recovery center in Boulder for 15 years, I've worked extensively with anti-craving modalities. GLP-1 agonists clearly attenuate reward-center signals in the brain, reducing cravings across alcohol, nicotine, and food.

Todd: Another established medication is naltrexone, an opioid receptor antagonist that blocks reward pathways.

Todd: Available in oral or monthly injectable form (Vivitrol), naltrexone significantly reduces heavy drinking days and craving intensity.

Todd: Combining low-dose naltrexone with a GLP-1 agonist can suppress afternoon alcohol cravings almost entirely. It comes down to weighing the benefits against the inconvenience of mental friction.

Todd: Naltrexone is effective, but it also blocks endogenous endorphins, potentially dampening positive experiences like a runner's high.

Todd: Because naltrexone blunts all opioid-mediated pleasure, a GLP-1 agonist is often preferable for individuals seeking targeted craving reduction without affective flattening.

Brent: That aligns with the Sinclair Method protocol for naltrexone. The trade-off—dampening the runner's high and everyday natural rewards—makes GLP-1 therapy more attractive for my situation.

Brent: GLP-1 agonists address cardiometabolic health and metabolic markers while simultaneously helping quiet cravings, providing dual benefits.

Brent: As clinicians, we aim to select interventions that address multiple health goals at once.

Brent: In your case, improving glucose regulation while curbing mild cravings makes GLP-1 therapy a compelling option.

Todd: Naltrexone has a strong clinical track record (Number Needed to Treat ~10) for severe alcohol dependence, whereas GLP-1s offer broader systemic benefits suitable for moderate preventative use.

Todd: Lastly, what about low-dose Cialis (tadalafil) for cardiovascular protection, as discussed by researchers like Dr. David Sinclair?

Todd: PDE5 inhibitors (such as Cialis and Viagra) promote vasodilation and lower blood pressure.

Todd: Emerging observational data suggest potential endothelial protection, making blood vessel linings less prone to plaque formation or clotting.

Todd: While large-scale clinical trials are still needed, daily low-dose tadalafil (e.g., 5 mg) is already FDA-approved for BPH (benign prostatic hyperplasia) and erectile dysfunction, offering potential endothelial benefits alongside established uses.

Brent: So the three main options to explore are: 1) Statin or PCSK9 inhibitor to target ApoB; 2) Low-dose GLP-1 agonist; 3) Low-dose Cialis for endothelial/cardiovascular support.

Brent: PCSK9 inhibitors specifically have data showing they can lower Lp(a) levels as well, which statins generally do not do.

Todd: A PCSK9 inhibitor, either alone or combined with a statin, could be a strong candidate given your specific biomarker profile.

Todd: We can evaluate those choices in our upcoming consultation, track the biomarker responses, and report back on the results.

Todd: Dr. Dorfman, thank you for joining and for your help with managing the anomalous right coronary artery. I went for a worry-free run this morning thanks to our work together.

Todd: I'm glad to hear you're doing so well. We'll speak soon.

Todd: Death Clock is recorded in Boulder, Colorado, and San Francisco, California. Produced by Patrick Gudino, music by Patrick Lee, and hosted by Brent Franson, founder and CEO of Death Clock.

Brent: So I think just to close, I think it it makes sense to experiment at least across two of these three categories, possibly across all three and report back. So number one statin or canine inhibitor and see what that does to apob specifically.

Todd: And sorry to interrupt Bram, but the canines have some recent data that they may be the only current medicine available to even lower that like a little AA, which is thought to be genetic, but that would be the only drug that you could point to. Some studies that show that at least at this time. So maybe we're leaning toward a Pcsk9 with you because of the lipoma and the fact that you don't have a lot of vascular disease.

Todd: But that's a nuance that you and I'll discuss.

Brent: Okay. So we'll we'll talk about the canine or stat and I would assume are those an either or are you couldn't some people do both.

Todd: Yeah. Most of the studies are actually in both. It's a it's a Pcsk9 added on to a statin. There are literally probably hundreds of studies with just the Pcsk9 alone or just the statin alone. But, it really depends on a couple of, factors and how low we want to get your LDL in your app will be.

Brent: There's some decision to be made in that category. It's one or the other or both. That's the first. The second is the GLP one. I think I'm very interested in this, just in the spirit of experiment, experimenting on myself and sharing the findings. And then the third category would be the low dose cialis. You and I have an appointment like a private appointment next week that we're not recording.

Brent: And so we can talk about this I will guinea pig myself and then we can, report back here together in a few months.

Todd: Yeah, I think I think that's great. We have a lot to talk about. We'll make some decisions and, see how you do.

Brent: All right. Wonderful. Doctor Dorfman, thank you so much, as always, for joining and and thank you for your help navigating the anomalous right coronary artery. I went on a run this morning. I wasn't thinking about it. And that's because of our work together. So thank you.

Todd: Good. Yeah. I'm pleased you're doing so well. And we will talk soon.

Brent: Death clock is recorded in Boulder, Colorado, sometime. San Francisco, California, produced by Patrick Gudino, music by Patrick Lee, and hosted by Yours truly. Brent Franson, founder and CEO of Dethklok.