AMA #2: Why a 'Perfect' LDL Won't Save You--Plaque, Statins & Metabolic Health

A live, unfiltered Ask Me Anything on preventive cardiology and metabolic health — recorded on about three hours of sleep after a night in the OR, which tends to make me a little more candid than usual. We cover the questions you actually ask: how plaque forms and how to stabilize it, what the "best" diet for cardiovascular health really is (spoiler: it depends on you), statins from every angle, Lp(a) and ApoB, the lean mass hyper-responder phenotype, GLP-1s and dementia risk, coronary CT angiograms and the AI tools reading them, carotid disease and how I think about stenting vs. surgery, and a few honest detours into supplements, what I eat, and why medicine is so much better at rescue than prevention. No oracles here — just an informed guide working the front lines, thinking out loud with a curious, generous audience. Use the chapters below to jump to whatever you came for. ⚠️ Educational content only. This is general information, not personal medical advice. Talk to your own clinician before changing any medication, supplement, or treatment plan. Chapters 0:00 — Welcome + how this AMA works 0:58 — High CAC score but a clean carotid duplex: how can both be true? 3:45 — Cleerly vs. HeartFlow: which AI coronary CT analysis is better? 6:26 — The "best" diet for cardiovascular health (there isn't just one) 10:59 — How to actually find a preventive / metabolic cardiologist 13:08 — Amlodipine, dizziness, and tachycardia after weight loss 14:41 — Do you need an ApoB test if LDL is already low on a PCSK9 inhibitor? 16:26 — The fibrous cap: can you thicken it and stabilize plaque? 18:59 — How does arterial plaque actually form? (Atherosclerosis 101) 23:47 — Beta blockers, AFib, and valve repair: a medication for life? 28:09 — When statins raise Lp(a) but lower ApoB 30:10 — How is familial hypercholesterolemia (FH) diagnosed? 32:20 — Erectile dysfunction and vascular health 33:46 — Statins, the full picture: benefits, side effects, and monitoring 45:23 — Lean Mass Hyper-Responders (LMHR), high LDL, and a clean CT 51:59 — Gene therapy for high cholesterol: promise and unknowns 56:04 — Rosuvastatin every other day vs. daily 57:20 — Best statin for ApoE4 carriers + the obicetrapib (CETP) story 1:00:57 — Easing statin muscle pain: CoQ10, vitamin D, gentler statins 1:02:15 — Is high cholesterol a sign of a liver problem? 1:04:24 — GLP-1s and dementia risk: what the data show 1:09:20 — Can your LDL be too low? 1:12:02 — Longevity influencers and GLP-1s 1:13:23 — Saturated fat and LDL cholesterol 1:15:22 — How often to order coronary CT angiograms — and why AI overlays worry me 1:23:19 — What tests prove your heart is healthy? (Why stress tests miss plaque) 1:28:24 — Citrus bergamot with statins or PCSK9 inhibitors 1:29:55 — Bypass conduits: mammary artery, leg vein, and radial artery 1:30:47 — What supplements I personally take 1:34:13 — What I personally eat 1:37:17 — Weak, rolling veins and difficult blood draws 1:38:12 — Why there's still no screening program for the #1 killer 1:44:42 — Is there a CIMT-style test for the heart? 1:45:43 — Post-COVID and post-vaccine vascular problems 1:48:13 — Can surgeons operate from a CTA, or is an angiogram needed? 1:51:25 — Do we use robots in vascular surgery? 1:54:29 — Carotid stenting vs. endarterectomy (and the CREST-2 results) 2:02:19 — Lp(a) of 295, Repatha, and when new Lp(a) drugs may arrive 2:04:17 — At what degree of carotid narrowing do you intervene? 2:07:01 — Book recommendations (and a preview of "Disconnected") 2:13:46 — Bonus: how much do I trust the gut microbiome science? Resources mentioned Bale-Doneen Method provider directory: https://baledoneen.com/find-a-provider/ "Healthy Heart, Healthy Brain" by Dr. Brad Bale & Amy Doneen: https://amzn.to/4o3GvGv My Lp(a) video series — start with the first explainer on how Lp(a) is measured (mg/dL vs. nmol/L) and the "Lp(a) — what now?" follow-up: Why You Need This Lp(a) Test Today High Lp(a)? Here's What Works (And What Do... My two videos on the lab tests I recommend beyond a standard annual physical (Lp(a), hs-CRP, fasting insulin, HOMA-IR, and more): 7 Life-Saving Tests Your Doctor Might Skip! 5 MORE Tests That Reveal What's Really Hap... Let's keep going If you'd like this to become a monthly feature, say so in the comments — and tell me which questions you want answered next time. Got a bike-tour recommendation? Drop it in the comments! High Quality 3rd-party tested supplements at Fullscript (10% discount): https://us.fullscript.com/welcome/ljo... ___________________________ 🧬 About Dr. Lily Johnston Dr. Johnston is a double board-certified vascular and general surgeon in San Diego, specializing in metabolic and cardiovascular prevention. She’s the founder of CorSight Health and a passionate advocate for reimagining how medicine approaches chronic disease.