High Cholesterol and What ACTUALLY Causes Heart Attacks with Cardiologist Dr. Joel Kahn

Are you one of the millions of midlife women confused about cholesterol, wondering if that number on your lab report is actually putting you at risk, or if you’re being prescribed medications you don’t really need? You’re not alone in this maze of conflicting information that’s been swirling since the 1970s.

As someone who’s personally navigated high cholesterol my entire life due to familial hyperlipidemia, I understand the frustration of chasing numbers while wondering what actually matters for heart health. When cardiologist Dr. Joel Kahn reached out after hearing me discuss this very topic, I knew we needed to have this conversation for all the women in our community who are drowning in contradictory advice.

The Shocking Truth About Heart Disease and Women

Heart disease is actually the number one killer of midlife women, yet we often focus our health concerns on cancer or view heart disease as primarily a man’s problem. While men typically present with classic heart attack symptoms and “drop dead” scenarios, women experience a completely different pattern of heart disease that’s often missed or misunderstood.

Women present with fatigue, palpitations, shortness of breath, back pain, arm pain, and jaw pain – symptoms that can persist for years before a cardiac event. Even more concerning, there are unique risk factors specific to women that many don’t realize can predict future heart problems decades later.

Hidden Risk Factors Every Woman Should Know

If you experienced preeclampsia, high blood pressure, or pre-diabetes during pregnancy in your 20s and 30s, you’re at significantly higher risk for clogged arteries in your 50s and beyond. These pregnancy complications serve as early warning signs that your cardiovascular system may be vulnerable later in life.

There’s also a particularly distressing condition called spontaneous coronary artery dissection that affects women during times of intense emotional or financial stress. Women experiencing this can show up in emergency rooms with classic heart attack symptoms, but when doctors examine their arteries, they appear clean – the damage comes from massive emotional and adrenaline responses.

The One Test Every Woman Over 45 Needs

Here’s what every woman needs to write down and ask their primary care doctor about: a coronary artery calcium score, performed through a CT scan. This test should be done when you’re 45 to 50 years old and repeated every 5-10 years if normal.

The test is simple – you lie on a stretcher, go into a CT scanner (not claustrophobic), hold your breath for 10 seconds, and go home. There’s no injection required, and it costs around $150 (though insurance coverage varies by state). The computer reads the scan and provides you with a calcium score that reveals whether you have calcified plaque in your heart arteries.

Understanding Your Calcium Score Numbers

• Zero: Excellent – very low risk of heart attack over the next 10 years
• 1-100: Low risk – less than 10% chance of cardiac problems
• 100-400: Moderate risk – requires lifestyle modifications and monitoring
• 400-1000: Higher risk – needs comprehensive evaluation and treatment
• Over 1000: Significant risk – requires aggressive management

According to Dr. Kahn, the critical point is that if you score zero, you likely don’t need statin medications unless you’re a smoker, diabetic, or fall into a small group of special circumstances. This test can literally save you from unnecessary medication while giving you peace of mind about your heart health.

When You Need to Go Deeper: The Cleerly Cardiac CTA Analysis

While the calcium score is an excellent starting point, it has limitations. It only shows hard, calcified plaque – like looking at the tip of an iceberg. It doesn’t reveal how narrowed your arteries actually are or detect soft, non-calcified plaque that can also be dangerous, especially in people with visceral fat, high triglycerides, low HDL, and high blood pressure.

This is where the Cleerly Cardiac CTA Analysis comes in – a more advanced test that’s been available for about five years. If your calcium score shows some concern, or if you have other risk factors, this test takes imaging to the next level.

What the Cleerly Test Involves:

• Uses the same CT scanner as the calcium score
• Requires an IV with iodine contrast (not radioactive, causes warmth for 20 seconds)
• Slightly more radiation exposure (3-4 times more than basic calcium score)
• Uses artificial intelligence software to read results
• Often requires cash payment due to spotty insurance coverage

What Cleerly Reveals That Calcium Scoring Cannot:

• Exact degree of artery narrowing
• Presence of soft, non-calcified plaque
• Detailed analysis of plaque composition
• Ability to track changes over time
• Whether plaque can actually shrink with treatment

This test provides the same level of detailed cardiac information that wealthy individuals like Elon Musk or Martha Stewart might access. You don’t need to be ultra-wealthy to get these insights, but you may need to invest in your health out-of-pocket.

Important Note: Even when a calcium score shows zero, the Cleerly test might reveal trace amounts of plaque. This doesn’t mean panic – it means you have more complete information to guide your health decisions and can catch issues in their earliest stages.

The Radiation-Free Alternative: CIMT Ultrasound

For those who prefer to avoid radiation exposure altogether, there’s another valuable test called Carotid Intima-Media Thickness (CIMT) ultrasound. This test examines the two arteries that feed blood to your brain and can provide insights into your overall arterial health.

Benefits of CIMT Testing:

• Completely radiation-free (uses ultrasound like pregnancy imaging)
• Takes about 15 minutes
• Can reveal if your arteries are aging faster or slower than your chronological age
• Shows soft plaque buildup and can track changes over time
• Can detect early arterial changes before they show up elsewhere

The CIMT test can reveal fascinating information – you might be 52 years old but have arteries that function like a 41-year-old’s, or conversely, discover that your arteries are aging faster than expected, prompting deeper investigation into the underlying causes.

Creating Your Personal Testing Strategy

If you’re starting your heart health journey:

1. Begin with the coronary artery calcium score (simplest, most cost-effective)
2. If results show concern or you have multiple risk factors, consider Cleerly analysis
3. For those avoiding radiation, CIMT ultrasound provides valuable arterial aging information
4. Combine any imaging with advanced blood work for the complete picture

Cholesterol: Separating Fact from Fiction

The cholesterol conversation has been ongoing since the 1970s, and the confusion is understandable. The first heart attack wasn’t even described until 1919, and what we’re seeing today in terms of frequency – one person having a heart attack every 42 seconds – is largely a modern phenomenon.

The landmark Framingham study, starting in 1948, identified the “big three” risk factors: high blood sugar, high cholesterol, and smoking. Simultaneously, researcher Ansel Keys observed that people in Mediterranean regions eating high-fat diets (40% of calories from fat) had virtually no heart attacks, while people in Finland eating the same percentage of fat from butter, lard, and cheese had the highest heart attack rates in the world.

When it comes to testing, the basic cholesterol panel most doctors order isn’t sufficient for truly understanding your risk. The LDL number you see is actually calculated using a 50-60 year old equation, not directly measured. Here are the tests that provide real insight:

Essential Tests Every Woman Should Request:

1. Lipoprotein(a) – A $25 test that 25% of people have elevated levels of this genetic cholesterol that significantly increases heart disease risk
2. ApoB – Measures all the “bad” particles in your blood; if this is low, you’re in good shape regardless of other numbers
3. Advanced lipid panel – Actually measures LDL particles instead of calculating them
4. MPO – Lets you know your inflammation and can help track the effectiveness of treatments aimed at reducing whole body inflammation and preventing further damage

These tests, combined with your calcium score, give you and your doctor the real information needed to make informed decisions about treatment.

The Statin Controversy: When Are They Actually Needed?

The official recommendation changed in 2019 when even the American Heart Association announced that if you have a calcium score of zero, there’s generally no role for statin medications unless you’re in a small group of high-risk individuals. This represents a significant shift toward testing for actual disease before prescribing medication.

Many women can safely discontinue statins if testing shows clean arteries and proper lifestyle modifications are in place. However, if you have significant plaque burden and genetic factors that don’t respond to optimal diet and exercise, a low-dose statin combined with ezetimibe may be appropriate.

For a 53-year-old woman with cholesterol of 245 and no known heart disease, you would need to treat an incredibly high number of women with statins to prevent one heart attack. For women with a calcium score of zero, this number becomes even more astronomical, making routine statin prescribing for these women inappropriate.

Blood Pressure: The Silent Killer

Ideal blood pressure is 110/75, though healthy, thin, athletic people may naturally run in the 90s without concern. However, numbers in the 145-150 range indicate hypertension that damages arteries and forces the heart muscle to age prematurely.

The systolic number (top) represents pressure when your heart beats, while diastolic (bottom) represents pressure when your heart relaxes. Both matter for heart health, and elevated blood pressure creates mechanical injury to heart arteries that receive the first impact of each pressure wave.

Before investing in expensive wellness gadgets, spend $90 on a home blood pressure cuff. Make “Blood Pressure Sunday” a family health activity – sit relaxed with feet on the ground, take three readings one minute apart, and track trends over time.

The Advanced Glycation End Products (AGEs) You Need to Know About

One of the most eye-opening aspects of heart health involves something called Advanced Glycation End Products (AGEs). These are chemicals created in your body that literally age your arteries, nerves, skin, and hair. 

AGEs form two ways:

1. High blood sugar – Chronic elevation glycates your proteins and fats, making them work poorly
2. High-heat cooking – Grilling, frying, or roasting high-fat, high-protein foods creates massive amounts of AGEs

The cooking method matters more than many realize. A piece of chicken made in a moist stew creates minimal AGEs, while the same chicken grilled or fried creates dangerous levels. Bacon tops the list as the highest AGE-containing food.

Heart-Protective Cooking Tips:

• Use moist cooking methods: stewing, braising, slow cooking
• Marinate meats in lemon juice, vinegar, or black beer before grilling to reduce AGE formation by half
• When eating grilled or fried foods, pair with large amounts of antioxidant-rich vegetables
• Consider an Instant Pot or tagine for flavorful, low-AGE meals

Supplements That Support Heart Health

Several supplements have strong research supporting their use for cardiovascular health:

Niacin (Vitamin B3) – Despite being dismissed by many cardiologists, randomized studies from the 1970s showed niacin reduces heart attacks, strokes, and increases longevity. It costs about 20 cents per day and causes a harmless flushing sensation.

Bergamot – This lemon-like citrus from Italy has been associated with longevity and can lower both blood sugar and cholesterol naturally.

Quercetin – Found in onions, garlic, and apples, this polyphenol supports endothelial function and has immune benefits.

CoQ10 – Essential for those on statins, but beneficial for heart health in general.

The Environmental Factors Destroying Your Heart

Modern life exposes us to numerous toxins that directly impact cardiovascular health. Recent research shows that 350,000 people per year die of heart disease due to phthalates from plastics alone. These endocrine disruptors impair thyroid function, blood sugar regulation, and cortisol production.

Simple Detox Strategies for Heart Health

• Stop microwaving food in plastic containers
• Avoid plastic water bottles
• Choose organic, green dry cleaning over PERC-based services
• Invest in home air and water filtration systems
• Read cosmetic ingredients and avoid products with unpronounceable phthalates
• Never use antibacterial mouthwashes like Listerine – they damage the endothelium

The Mediterranean Connection

The Mediterranean diet pattern remains one of the most researched approaches for heart health. In Spain, a randomized study of heart patients found that those consuming five tablespoons of olive oil daily had significantly fewer heart attacks than those eating less than one teaspoon daily. Even more remarkably, their arterial plaques were actually shrinking.

This doesn’t mean you need five tablespoons daily, but it reinforces that quality fats like olive oil, nuts, and seeds should be emphasized over processed alternatives.

Your Action Plan for Heart Health

Based on this comprehensive discussion with Dr. Kahn, here’s your practical roadmap:

Immediate Steps:

1. Schedule a coronary artery calcium score if you’re 45 or older
2. Request the advanced tests: Lipoprotein(a), ApoB, and advanced lipid panel
3. Invest in a home blood pressure monitor
4. Evaluate your cooking methods and reduce high-heat preparation

Ongoing Lifestyle:

• Prioritize whole, unprocessed foods regardless of your dietary pattern
• Include plenty of antioxidant-rich vegetables with any animal proteins
• Choose olive oil as your primary added fat
• Maintain a healthy weight and stay physically active
• Address sleep quality and stress management
• Reduce toxic exposures where possible

Working with Healthcare Providers:

• Don’t accept statin prescriptions without proper testing
• Ask specific questions about your individual risk factors
• Consider working with a cardiologist who emphasizes prevention
• Get second opinions on medication recommendations

Heart disease in women is complex, often presenting differently than in men, and influenced by factors unique to the female experience. The good news is that with proper testing, you can get real answers about your personal risk and make informed decisions about treatment.

Whether your cholesterol is 180 or 280, whether you’re vegan or follow a different eating pattern, the fundamentals remain the same: real food, appropriate testing, individualized treatment, and lifestyle factors that support cardiovascular health throughout midlife and beyond.

Remember, you don’t have to navigate this alone. Find healthcare providers who take the time to explain your individual situation and support your journey toward optimal heart health. Your heart – and your family – depend on the choices you make today.

🔗 Resources mentioned:

• Dr. Joel Kahn’s website: drjoelkahn.com
• Prevent Calculator: https://professional.heart.org/en/guidelines-and-statements/prevent-calculator 
• Book: “Lipoprotein(a): The Heart’s Quiet Killer” 
• Study Dr. Kahn was co-author on establishing lifelong exposure to either slight reductions in LDL-C or slight elevations determines heart disease risk long term. Widely quoted paper: https://pubmed.ncbi.nlm.nih.gov/23083789/
• The most widely quoted paper establishing LDL-C as a cause, not just risk factor, of atherosclerosis: https://pubmed.ncbi.nlm.nih.gov/28444290/
• A recent paper on Lipoprotein(a) cholesterol inherited by 20-25% of people, not currently FDA approved Rx as statins do not work for it, but new Rx med in the pipeline. Similar risk to men and women: https://pubmed.ncbi.nlm.nih.gov/40240882/

The contents of the Midlife Conversations podcast is for educational and informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always consult with a qualified healthcare provider. Some episodes of Midlife Conversations may be sponsored by products or services discussed during the show. The host may receive compensation for such advertisements or if you purchase products through affiliate links mentioned on this podcast.