New Heart Health Guidelines with Dr. Khadeeja Esmail

New Heart Health Guidelines: The Cardiologist's Guide To Lipid, Blood Pressure, And Cardiovascular Prevention With Dr. Khadeeja Esmail

Welcome to the Duration Wellness Show. I’m excited to have you here. The show is for basic medical awareness and health education. It is not intended as medical advice. I’m excited about our guest, Dr. Khadeeja Esmail, who is not only board-certified in internal medicine and cardiology but also an associate professor. She actually teaches our new cardiologists and fellows, who are just amazing. We are basically here to talk about cardiovascular prevention and heart health. I’m so excited for you to be on the show. 

Thank you.

I know that was a little intro. I do not know if you want to do a little bit more.

Excited to be here. I actually did our training together at UF, and I stayed on for cardiology training and as faculty here. I am in year six of my faculty here as an associate professor. I am also in charge of the ECHO Lab here, so medical director of the ECHO Lab. We have a cardio OB program that I am involved in, as well as cardiac rehab and teaching the fellows. A little bit of everything here, but prevention is really one of the big things that I am interested in. I am really excited to be here to talk to you guys about it.

I cannot wait. It is something that I am very passionate about, too. It is so much better if we can stop or it is way better to prevent a heart attack than to have a heart attack and then treat it. It is just so important. Getting into it, what would you say are the biggest cardiovascular risk factors that you see patients coming into your clinic with?

Major Cardiovascular Risk Factors

The big things really are hyperlipidemia. Elevated lipids, elevated LDL, total cholesterol, and triglycerides. High blood pressure is a big one, and a lot of people go a long time without knowing they have high blood pressure. They do call it the silent killer because it really affects a lot of people. Blood pressure is another major risk factor.

Tweet: High blood pressure is a major risk factor, and many people live with it for years without knowing. That’s why it’s called the silent killer—it affects so many people without warning.

Another really big one is obesity. Now with these GLP ones, we are trying to tackle that. Obesity is another major risk factor because fat cells release a lot of inflammation into the body. Those are the main ones, specifically for women, too. Preeclampsia, premature delivery, gestational diabetes, and gestational hypertension. These are all major risk factors as well for coronary artery disease.

I think a lot of people do not realize that when they are pregnant, because they usually view it as a temporary diagnosis, since they just had it during pregnancy. People do not realize that a lot of times, when you have these gestational diabetes, gestational hypertension, and preeclampsia, that sets them up. They are in that higher-risk category for all of these. It is a warning sign that you are at a higher risk of developing diabetes if you have gestational diabetes or a higher risk of developing hypertension. A lot of people do not realize that that is in that category too.

I ask all of my patients when I am seeing them in clinic, did you have any preeclampsia, any of these risk-enhancing conditions? We can really get a good risk assessment for our patients.

What about sleep apnea? Do you find that it is kind of related to or not as much?

For a lot of other conditions, it is all related. Sleep apnea definitely increases blood pressure, which in turn increases your coronary artery risk. It also increases arrhythmias, the heart rhythm issues. They are all related. That is part of our screening as well, and making sure that they do get a sleep study if they have the criteria that we are looking for.

I know you said a lot of people do not know about their blood pressure. I find it so true. I will have patients who come into the hospital, and they are hospitalized, and they are like, “I do not have any medical issues.” You are like, “Your blood pressure is insane,” but they never write it. You can go into grocery stores. A lot of them will have those cuffs that you can use to check. Now it is so easy to get the over-the-counter cuffs where you can just have it from home and monitor, and people do not realize how important it is to be checking those. It is so important.

When we do see them in the clinic, and if their blood pressures are elevated, we make sure we get some readings at home because they can have white coat hypertension. They are just stressed out about the visit and are all anxious, or they went through a lot of traffic. We do like to get those readings to the side of the clinic visit to just really confirm, but really, I think everybody should have a blood pressure cuff at home, especially if they have a diagnosis of high blood pressure.

Interpreting The Standard Lipid Profile

It’s very helpful. You were talking about lipids, which I think brings up the next question that I think people should be aware of. How should patients think about their lipid profile for heart health? Cholesterol screenings are a good thing, as they are becoming more common, and people are becoming more aware that they need to know this. How should people look at those and interpret them?

There are a few different components of the lipid panel that I want to go over. The first one that you will see is the total cholesterol. That is basically the sum of all the cholesterol in your blood. If you think about your arteries like a highway, it is basically all the total traffic on the highway, but it does not tell you the good cars versus the bad cars. That is when we get some other data. The total cholesterol includes the LDL, which is our "bad" cholesterol, the HDL, which is our "good" cholesterol, and also the VLDL.

Typical values that we are looking for in the normal range is less than 200. The LDL is calculated, but it is not actually measured. That is our bad cholesterol. Those are basically the cars that are dumping the cholesterol into the artery wall, which is the main driver of plaque buildup, atherosclerosis. This has a strong link to heart attacks and stroke.

Depending on what your risk profile is and what your history is, typically our goal is less than 100. If you have a history of heart attack or stroke, we tend to go with lower values. That is tailored a little bit to the patient. For the general population, less than 100. We have our good cholesterol, the HDL. This is basically the cars that are taking away all of the bad cholesterol from the artery. It really helps remove cholesterol from the arteries.

Typically, greater than 60 is cardio-protective. People ask, how do we improve our HDL? Exercise is one of the things. The caveat is, they have checked it, and really, a higher level is not always necessarily that good. Triglycerides are basically the fat in the bloodstream. The high level is linked to metabolic syndrome and diabetes. The value that we are looking for for triglycerides is less than 150. 

I heard somebody say once, and obviously, there is the genetic component of triglycerides too, so this is not for everybody, but that a lot of times it can be one of the first pickups that people are on their way to diabetes. Even sometimes pre-diabetes, before they realize that you can actually see it in those triglycerides starting to go up, which I thought was interesting. I did not realize that before.

Definitely, all of these values are important to look at, and they all give us an insight into what is going on. Triglycerides are the ones that are really linked to diabetes and metabolic syndrome. One that is really important that a lot of people do not look at is the non-HDL. The non-HDL is basically the number of all the particles in your blood that can cause plaque. It is your LDL, the remnants, the very low, and the intermediate.

Non-HDL is actually a very important number to look at, and it is in a way, it is like the cheap way of calculating an APOB. We are going to talk about ApoB next, but to calculate your non-HDL, which your lipid panel will show you, is your total cholesterol minus your HDL. It basically should be less than 130. These are all the atherogenic particles in your blood. A very important number.

You can get that then on just a generic cholesterol panel.

The Importance Of ApoB And Lp(a)

Correct. Usually, they do report non-HDL, but that is a really important number. We want it less than 130. Those are all the bad particles. The newer ones are ApoB, and that is also the number of atherogenic particles. What we have realized is that it is the number of particles that really causes the issues. We want to know how many of these bad particles we have in our bloodstream. That is where we get our APOB, which is essentially very similar to our non-HDL. For the APOB, we do want it less than 90. Again, there are different goals based on what your risk is. Generally, less than 90 is optimal.

Do they risk-stratify that by age? No, it is just kind of a general for everybody below 90?

General for everybody. If you have an elevated lipoprotein A, which is a genetically determined LDL-like particle, but it is extra sticky. It forms plaque way more at a younger age. This is something that really everybody should have checked. We are going to go into the new guidelines for lipids in a little bit. Basically, there are two different cutoffs depending on which unit you are using. Less than 30 for milligrams per deciliter and less than 75 for nanomoles per liter. This is a really important article because again, it is extra sticky, it gets in those arteries, it forms clots in there too, and it is prothrombotic. This one is a nightmare. Lipoprotein A is a really important marker that everybody should really have checked. 

Tweet: If you have elevated lipoprotein(a)—a genetically determined LDL-like particle that is especially ‘sticky’ and prone to forming plaque earlier in life—it’s something everyone should get checked.

You said that one is genetic. Is there a way to really decrease that as much as possible, or is it more than you have to try to decrease all the others?

As of now, the trials are ongoing to test the medications to lower your lipoprotein A and also to see what cutoff. How much do we really need to lower it by 50% or 30% to make a clinical difference? Right now, there is no medication to lower it, but what we are recommending is if you do have an elevated LP, a little a is to decrease your ApoB and your LDL. That would be via exercise and diet. Generally, we would recommend the medication. Generally, for most of our patients, we do recommend the Mediterranean diet and exercise at least 150 minutes per week. If you are not meeting your goals of APOB and LDL, then you might have to turn to medication like statins to help you lower your risk. 

Aerobic Exercise Goals For Vascular Health

Where the exercise, 150 minutes, is that like 150 minutes of walking? Is it weights? Is it a mix, or what is the thought?

Moderate exercise, and it can be broken up as much as you want. Twenty minutes here, 30 minutes here, aerobic exercise, so moderate intensity aerobic exercise. Strength training also does have its benefits, but in terms of cardiovascular, we recommend aerobic exercise.

Specifically for cardiovascular health. Interesting. Was there anything else in that?

Those are the main things in the lipid panel that you really want to look at.

The next question, which kind of goes into the lipid panel, is that I think most people get a standard cholesterol panel. It has the LDL, the HDL, and your triglycerides, but there is also this particle-based profile. A lot of people are not quite as aware of. What do you think? Is that better for everyone? Is it just a certain population that needs that? What does it include?

For the particle, basically, that test gives you the number of LDL particles as well as the size. What we know is that the small particles are worse. The small LDL particles are able to get into the arteries a lot easier than the fluffy, big LDL. If you have a lot of small particles that increases your risk. Who would I get this from? I would get this on patients who have a very significant family history of premature coronary artery disease. Those would be the main ones, or really elevated LPA, just to get some more idea of what is going on with their LDL and what the numbers are.

That makes sense. You were saying they came out with new guidelines because before you had to really ask for your ApoB and lipoprotein A. How has this changed in the new guidelines? Is it the same, or what are the changes there?

New Guidelines For Universal Lp(a) Screening 

I am really excited about this new guideline that just came out this month. The timing of this podcast is perfect. Basically, guidelines are saying every person should have an LP-Lik-Delay tested at least once in their lifetime. You just need it once. It is genetic. It is not going to change. You basically just need it checked one time. That is the first thing that is new with this new guideline. The second thing is they are talking about early screening as young as nine years old because plaque buildup really starts when they are toddlers. Early screening starting at age nine for everybody.

Which is wild. That is in the pediatric population, and for people to know who have kids that they want to be asking for this. Your lipoprotein A really should be the same when you are twelve as it is when you are 50. Interesting. 

What is interesting, too, is that I had mine checked recently, and it was actually elevated. As a cardiologist, that definitely did not sit well with me, but it is genetic. What is interesting is that when you do have an LPA that is elevated, your kids should be checked as well. Starting as early as five years old, you can check them, but I do not know who wants to try and get blood from a five-year-old. You can wait until they are 9 or 10. They should be checked as well. 

That is interesting. It does help to have real numbers for people to put in perspective. I figured we talked about mine because I went and got all this, and then it scared me because I was already exercising and being healthy. It will give a little bit more practical application for our audience, hearing and seeing a profile. My LDL was 113, but my particle number was 1,659. Of that, because then we were talking about the small, medium particles, the small LDL was 251, and then my medium was 311. My LDL pattern was A, which we did not really talk about patterns. What do you think about patterns?

Patterns, the A class is the higher risk category. At this point, we do not really have anything that can lower these particle numbers or the LPA, but it is going to be mostly lifestyle modifications. If we are not reaching our goal for LDL, then it would be a statin. You have basically a lot of small particles and a good number of them. These get into the arteries a lot easier. It definitely increases your risk of plaque formation.

Which is what I was worried about. On top of that, my apolipoprotein B was 91. My lipoprotein A, little a, was 90. 

Your apolipop was right at the border, right? Less than 90 is our goal. You're right at the border for apolipop B. Your LDL is elevated, and your lipoprotein A is elevated. For you, the goal would be to get your ApoB less than 60 and your LDL less than 70. It’s tough. You are already doing all the good things. The next step may be to consider a statin to decrease your cardiovascular risk.

I did a deep dive on some of this stuff and anything that I could be doing. The only thing that really came up, and we will see as I am going to repeat my cholesterol panel, is that I was using the French press, which does not filter out some of the oil particles. There are some things where it says that that can maybe increase it. I changed that, and I need to up my activity because I have been doing more weights. That is not quite as much in terms of the aerobic exercise, which goes more with the cardiovascular profile.

Role Of The Coronary Calcium Score

Those are the interventions I am doing now to see if that helps at all. We will see. I went, and because of all of this, I was like, “I want to see how my arteries look, what we call coronary calcium.” A CAT scan to look at the calcium that is in my heart arteries, which was good. It does not go into all of the softer plaque, which is the more dangerous plaque. What do you think in terms of when someone has these abnormal profiles and when they should get imaging?

We do have quite a lot of tools within cardiology. One of those is the calcium score. Basically, this is a quick non-contrast CT. It does not take very long at all, and they just measure your plaque burden in terms of the calcified plaque. That is a good tool to use if you do have elevated lipoprotein A and you are seeing all these high-risk things. You can ask your physician to order the calcium score. It does not pick up the soft plaque or the vulnerable plaque that may be lingering.

As of now, if you do not have any symptoms, insurance does not cover the coronary CTA. That is a full CAT scan with contrast that is looking for those soft plaques. Without symptoms, the best bet right now is a calcium score. That basically gives us a score from zero, which is what we want, all the way up to thousands. Based on that, we would decide what further testing we would need. 

Where is the cutoff in terms of when you would recommend somebody to go get that versus waiting and watching based on their LDL numbers? How often are you saying, "Let us just do these modifications and come back in three months, and we will repeat your cholesterol panels?" What is your cutoff versus just going straight to it?

It is also age-dependent because it takes a while for calcium to build up in the coronaries. Typically, I do not recommend these calcium scores for anybody under the age of 35. 35 is my cutoff. If they have an elevated LPA, I would say to get the calcium score if they are above the age of 35.

Tweet: It takes a while for calcium to build up in the coronary arteries.

That is good to know. We went into it a little bit. The lipoprotein A is just so that audiences understand, because it is confusing. Lipoprotein A is what is genetic and really cannot be changed, but it is like a warning that you are at a higher risk. You can change your apolipoprotein B and LDL.

Your triglycerides are a function of diet and HDL to a certain extent as well. 

Is there data on how much LDL and apolipoprotein B can be changed by diet versus exercise? Is there not really much in terms of stratifying those out, or do you just really need both?

There is no real data on that. We just do as much as we can with lifestyle modification to avoid having to start medication. Sometimes you are going to need it because you are fighting genetics, and there is only so much you can do. 

I know you mentioned the Mediterranean diet. That is something that you typically find is very helpful.

With regards to diet, that is the one we find is most sustainable, which has good data behind it. That is essentially limiting the red meat to once a week. Really, no processed red meat. The processed meats in general are basically carcinogens, the same as smoking. We help patients by telling them to please avoid those processed meats like hot dogs and cold cuts. Obviously, fruits and vegetables are included. With fruits, we recommend a lot of berries.

They have a lot of antioxidants, especially blueberries. Nuts like walnuts are good, especially walnuts with blueberries together. That is a really good combo to help with decreasing the oxidation. Fish is important. We are okay with chicken and healthy fats, olive oil, and avocados. That is what we are recommending, combined with the exercise. Those are the two main things you can really work on that you have in your control.

Tweet: Diet and exercise—those are the two main things you can truly control.

It is nice that there are things that people can change. Diet and lifestyle do have an effect. I think a lot of people talk about fish oils. How much do you find that those help? If somebody is on the Mediterranean diet and they are exercising, but their numbers are still not optimal, do you find that adding fish oil helps?

The data is not that great. I do not routinely prescribe it for my patients. Rather, I will just tell them to eat their fish, and as much as you can try for wild fish, not farm fish, because there are just a lot of toxins there. I do not routinely prescribe fish oil.

I am curious. I feel like there is more coming out about microplastics and that affecting cardiovascular health. There is probably no data in terms of it affecting LDL, but do you think microplastics are something people need to be aware of and worried about?

There is an interesting study where they actually looked at cadavers, and they found microplastics in the coronaries. These microplastics are really everywhere now. At least in our home now, we have tried to replace as much as we can, especially for our kids who are young. We are really trying to avoid plastics because there is still so much we do not know, but we do know it is infiltrating everything in the body. The more you can avoid plastic, the better.

It is so wild how it is everywhere now. That is the main stuff for the lipid panel and the particle-based profile. 

Statins Stabilize Vulnerable Plaque

I do want to say something about statins in general because there are some misconceptions and some negative connotations with that medication. What the statins do is they basically stabilize the plaque. They turn those vulnerable plaques that are likely to rupture and cause a heart attack into a thicker-walled calcified plaque. What is interesting is that your calcium score does tend to go up a little bit because now those soft plaques have turned into some hard plaque that is less likely to rupture.

It really decreases inflammation at the artery level, stabilizes the plaque, and decreases your risk of a heart attack. They have done a lot of studies to investigate the side effects. Many people report muscle pain when they are starting the statin, but I think it is something that they have just heard is a possibility. Part of it is probably just from that, but they have done a lot of studies where they had people on a statin, and they did not essentially tell them, and they had no symptoms at all.

They were on a placebo, and they were still having the same amount of muscle pain as the other group. The risk of actual myositis inflammation of the muscle causing issues is very low. These statins are well tolerated based on our big studies. They really should not be increasing any pain in your muscles. They are very beneficial.

I do think a lot of people are like, "My goodness." Now they have changed the recommendations regarding the ages for screening and when to start statins, depending on your LDL levels and cholesterol. Some people are like, "That is really young," but it is also much better to prevent a heart attack than to have to treat one. I know many people talk about the side effects. Do you find that the data is very mixed on CoQ10? Do you give it? 

I do because I think there has been some good success when I have given it to patients. There are really no side effects with it. If they are complaining of having muscle pain, then I will prescribe that, and I will tell them, "You can take your statin every other day. Start taking it every other day and see how you are doing. You can take Coenzyme Q10 and let us see how we are doing." I usually will start at the lowest dose and work up from there.

I find it interesting. I think there is a side effect of statins where they can increase your insulin resistance slightly, but overall, they are still so effective in terms of cardiovascular prevention. Do you see that a lot?

No. 

It is just an interesting thing how it works. We do have a lot of data on it. It does help many people. I think many people are not aware of how it stabilizes plaque and that vulnerable plaque is really the issue.

What they found is that the plaques that rupture, causing heart attacks, are actually those moderate lesions, those 40% or 50% lesions that rupture because it is a vulnerable plaque. The statins really help stabilize, calcify, and thicken those plaques so that they do not rupture.

Break off, and then cause that acute blockage. Let us see. We talked a little bit about blood pressure. I did not know if you wanted to go into that a little bit more in terms of why it is so important for prevention.

The Importance Of Blood Pressure Control

High blood pressure puts an injury to the walls of the arteries. Anytime there is either a mechanical insult to the artery wall or inflammation from something else, the plaque is just going to accelerate. High blood pressure is one of those things that accelerates plaque because of the increased pressure in the artery walls. Having that under control is a huge benefit and decreases your risk of heart attack and stroke.

Tweet: High blood pressure accelerates plaque buildup by increasing pressure on the artery walls. Keeping it under control is a major benefit that significantly lowers the risk of heart attack and stroke.

Blood pressure control is so important. A lot of times, people do not realize it. We’ve talked about it earlier that they’re walking around with high blood pressure because they’re not checking it. Now, it’s so easy to get those home blood pressure cuffs that people can check to make sure that they’re at a normal level and everything. There are some treatments. Exercise is going to be your number one treatment for that anyway. A lot of times, people are exercising and having the right diet. If they’ve been overweight, then lose some weight. Many times, that in and of itself will help control the blood pressure.

I really try to do the least amount of medicine possible. If the patient is starting to lose weight, we are able to slowly taper it off. I tell them this is not forever. We are putting these medications on now, but if we are able to lose weight and do all these things, then we can come off some of these medications. I have taken patients off a lot of their blood pressure medications because they have been doing really well with that lifestyle modification.

That is also something to remind people of. There are a lot of things that you can do in terms of adjusting these risks that are non-medication. That is the goal, is to actually make these lifestyle changes. It is just hard. It does take work to do the exercise and to eat healthy, but it is very doable, and it can have huge effects in terms of not being on the medicine.

Really getting all these things checked does motivate you. When I got my LP levels checked, and it was elevated, it really motivated me to do a lot better. I would indulge in the cookie here and there, obviously, but now I am turning to healthier options. My baseline was pretty good, but there is always room for improvement. It really motivates you to do better. That in itself is a good reason to get it checked.

I agree. It is like you can do these lifestyle changes, and then you can follow up and see how it has changed. If you still, even with everything else, are in that increased risk, then that is where, at least, there are medications, and there are other options in terms of helping with prevention. It is so important. We did not even mention smoking, but I think it is just probably because it is a given that smoking is very bad for heart health.

The American Heart Association has its Essential Eight, which are basically all the things that you should do to decrease your risk of heart disease. Smoking cessation is obviously on there, as is exercise, diet, and sleep. They also have a calculator where you can plug in all this stuff and see where you are at. The other calculator that now based on the new guidelines is coming into favor more is the PREVENT Risk Calculator. That is available online. You could just plug in your information, and it gives you your risk of heart disease.

Recommended Sleep Hours To Decrease Risk

That is cool. PREVENT Risk Calculator. That is good for people to know. Let us talk about sleep then. How would you say sleep ties into heart health?

It is one of the Essential Eight from the AHA. Their recommendation is 7 to 9 hours of sleep a night. Not many people are hitting that for multiple reasons. I have two little ones, and for a long time, the sleep was really broken up.

Not to mention when we did fellowship and residency.

It has not been great for a long time. Basically, what happens when you do not get enough sleep is that your body increases its sympathetic drive. You have a sympathetic parasympathetic system. Sympathetics is like the fight or flight, and causes blood pressure and heart rate to go up. When you do not get enough sleep, that system takes over, and that will increase your blood pressure. One way to really help with blood pressure is to get good sleep.

Tweet: One of the simplest ways to support healthy blood pressure is getting good sleep.

The other thing is that decreased sleep increases the inflammatory cytokines in your body. Inflammation is one of the main drivers of any chronic disease. Minimizing inflammation in the body is really the goal. Decreasing those inflammatory markers by sleeping well is really what you want to aim for. Seven to nine hours is the recommendation to decrease cardiovascular risk. 

We probably should have talked about it in the cholesterol panel, but regarding the inflammatory markers like CRP that you mentioned, when would you say patients should get that checked?

I would say everybody should get a CRP. I do not routinely check the other ones, like IL-6 and TNF-alpha. I do check a CRP in everybody just to get a baseline to see where there is inflammation and what’s going on. Everybody should get that checked as well.

Routinely Check CRP For Baseline Inflammation

As you said, inflammation is at a very high risk in terms of cardiovascular disease, autoimmune diseases, and cancers. Dementia is also included. Overall, decreasing your inflammation burden is so important. It is very helpful. The heart part is not specific and does not say, “This is what is going on,” but it does show that there is increased inflammation. You can try to decrease your inflammatory burden as much as possible.

Sleep is super important, which we know, and that is why at the show, it is one of our focuses. I had a study here that I thought maybe we could talk about a little bit. It was looking at insomnia symptoms and cardiovascular disease. It was a longer cohort study. Sleep studies are hard because you cannot say, "You are sleeping, and you are not." It cannot be double-blinded, where people do not know if they are sleeping well or not sleeping well. That is a hard part about sleep studies. I just thought maybe we would talk about it a little bit.

What I liked about it is that it covered cardiovascular disease over ten years, which is a significant amount of time. It also had a large number of patients in it. There were over 45,000 people who were recruited into it to look at their sleep. They used a questionnaire to gauge how well they slept. The worse their sleep was, it was correlated with a higher the risk of cardiovascular disease. If your sleep is not ideal, but it is not horrible, you have a little bit increased risk. As your sleep gets worse, it is really associated with a higher risk. I do not know what you thought about it in terms of the study.

When we are looking at studies, there are a few things that we look at to make sure it is an appropriate study. A number of patients is a big one. As you talked about, there are inherent flaws in these types of studies, but there were a lot of patients, and I think it was a relatively well-done study. It confirms what we know about decreased sleep and cardiovascular risk. It is super important. One thing I also started doing because I am about to be 40 this year is that I got one of the wearables.

I think that was a big wake-up call. “I’m about to get 40. Let’s make sure we're doing this together. I have two little kids, and I want to make sure I am healthy for them.” They just give you so much valuable information, especially for sleep. It tells you your sleep efficiency. Sleep efficiency tells you how much deep sleep, REM, and when you are awake. You can see how some of the lifestyle choices you make affect some of these sleep things.

I am a big fan of these wearables that they have out now for the sleep data and for recovery. Mine does EKGs and blood pressure. It helps track your menstrual stuff and your hormones. Part of this is where I got all those biomarkers. There are a lot of good tools out there right now, and I think these wearables really have a good part in prevention. The data you get for sleep on there is just amazing.

Especially when they are saying that you need seven to nine hours, I think many times people do not quite know where to start. I have a wearable too, and then I can actually have evidence. “Last night I ate a little bit later, and my deep sleep was way worse.” If I had a glass of wine, I could see that my sleep was trash. If I did the sauna, I slept way better. These things are like you do not always feel it the next day. It is really helpful to also have the data there, as it had a great effect.

Workout too late. It gives you a lot of good information for you to help target your lifestyle choices.

I will say something in this study that I found a little bit interesting. I would be curious to see if the other sleep studies in terms of cardiovascular risk tease them out. I do not think that they do. If sleep apnea is a big driver for a lot of it, because some of the people who had a higher risk were people who seemed to be at a higher risk for sleep apnea too.

Sleep Apnea's Negative Toll On The Heart

Sleep apnea is huge in the cardiovascular world. It does decrease your sleep efficiency because you are having these episodes of apnea. Sleep apnea affects blood pressure and causes it to go up. It causes heart rhythm issues, causes a strain on the right side of the heart, and can lead to heart failure, pulmonary hypertension, and really affects many things in the body. That is a really important thing.

Tweet: Sleep apnea raises blood pressure and disrupts heart rhythm, placing strain on the right side of the heart. Over time, it can contribute to heart failure, pulmonary hypertension, and widespread effects throughout the body.

If you are being told that you snore or you have episodes where you stop breathing, if you have a really large neck circumference and are overweight, and you wake up and do not feel good or you fall asleep easily, these are signs that you could have sleep apnea. You should ask your doctor to order a sleep study because sleep apnea really has a big toll on the heart for multiple reasons. 

The diagnosis because you used to require going into a sleep lab, and people would watch you. People hated that. Now there are many options. Many times, they can even go from your home. People have not realized how that has changed, where it is a lot easier to get tested and not have to go into a sleep lab.

Even the actual masks and stuff have also changed. There are many that are not these big chunky masks that go over your whole face. There are some now that just look like the nasal cannula for oxygen. They are really small. There are many more options now for treatment as well that are a little bit more streamlined and not so bulky.

We touched on it a little bit in terms of sleep and how when people are sleeping less, it affects blood pressure. Blood pressure can go up. That is a part of blood pressure control. Have they had any associations in terms of cholesterol and LDL? There are no real studies on that.

I have not seen any.

I had not seen any either. I would be curious about that, though, because not having enough sleep does affect inflammation. It does have an effect on all of the inflammatory markers.

Magnesium Supplements For Sleep And Heart Rhythm Stabilization

When my patients tell me they cannot sleep, one of the first things I do is check their sleep hygiene. Many people are lying in bed on their phones, doomscrolling, and are on their devices. We go through sleep hygiene. I spend a few minutes and see if I can figure out what they are doing that is not great. There is a role for supplements. Magnesium definitely is something I prescribe to all my patients for multiple reasons. One is for sleep. Two is for heart rhythm stabilization.

For patients who are having these early beats from the bottom chamber, we call PVCs, before going to our other prescription drugs, I go for magnesium. Most people are deficient in it anyway. There is a big role for supplements in cardiovascular health and immune function. Vitamin D is another huge thing. There’s a big role for all of these things. When you look at your labs as a whole, part of it should be your vitamin levels and trying to tie everything together to optimize your health. Supplements play a big role in that.

One of the other things that I got checked was my magnesium level and the red blood cells so that I could see what my true level was at. I was low, even though I supplemented with it, and I had a healthy diet. I am sure there are genetic factors. Do you have a specific type of magnesium, like magnesium glycinate or citrate? What is your usual type?

My go-to is usually glycinate. That is the one I usually prescribe. I am telling them 200 milligrams twice a day, and they can go up to 400 twice a day.

That is also what will help many people sleep. In our sleep club, we use magnesium glycinate. I think there is a lot of good data in terms of its absorption level and helpfulness. That is awesome. Is there anything else that you can think of?

In today's world, the more information you have, the better for longevity. Get your labs checked and get a wearable. If you are able to afford a wearable, go ahead and get one. Just make sure the one you get can track your sleep, as that will be really beneficial. Get a wearable, get your data, and find a good primary care provider that can tie this all together. Be an advocate for yourself. You have all this information, so be an advocate. Try and do the healthy lifestyle as much as you can to decrease your risk. Get that information and see what your risk profile is.

That is awesome. Excellent advice. There was a lot of practical and useful information for everybody. Now that they have the information, they have the tools that they need to ask for this and take their health into their own hands. Thank you so much. This was awesome.

Thank you. It was a pleasure.

For everybody tuning in, another fun episode at the Duration Wellness Show. We will have more soon. 

Important Links

• Dr. Khadeeja Esmail
• PREVENT Risk Calculator
• Healthy sleep patterns reduce the risk of cardiovascular disease: A 10-year prospective cohort study
• Insomnia symptom trajectories and incident cardiovascular disease in older adults: a longitudinal cohort study
• Free Lipoprotein(a) testing

About Dr. Khadeeja Esmail

Khadeeja Esmail, M.D., is a University of Florida assistant professor of medicine and a board-certified cardiologist at UF Health Jacksonville. She also serves as associate program director for the Cardiovascular Disease Fellowship.  One of her passions is the topic of cardiovascular preventio