Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients.

Podcast Summary

Introduction

Dr. Warrick Bishop, a practicing cardiologist and patient education advocate, hosts this episode with Dr. Karam Kostner, a leading lipidologist and colleague. The episode explores LDL particle size—a topic that frequently appears in social media and diet-related discussions—and examines whether different sizes of LDL cholesterol particles pose varying risks to heart health.

Key Takeaways:

• Lipoproteins are protein carriers that transport cholesterol through the bloodstream; they can be understood as "buses" or "sedans" carrying cholesterol molecules, with density and size varying based on how packed they are.

• While LDL particles do come in different sizes and densities, approximately 99% of all LDL is problematic regardless of particle size, as clinical trials consistently show that all LDL ends up in arteries and contributes to plaque buildup.

• Small, dense LDL particles may be slightly more atherogenic (artery-damaging) than larger particles due to their ability to penetrate vessel walls more easily, but this distinction has limited clinical importance.

• For clinical practice, measuring LDL particle size is not recommended because reducing overall LDL cholesterol—regardless of particle composition—effectively reduces cardiovascular risk in both diabetic and non-diabetic patients.

• Diet, exercise, diabetes, and medical therapies (statins, fibrates, ezetrol) all influence LDL particle size, but the primary clinical focus should remain on lowering total LDL rather than targeting specific particle sizes.

• Particle size testing, while commercially available and scientifically interesting, is primarily a research tool with limited practical utility for patient management at this stage.

• The danger exists that patients with favorable particle size profiles may incorrectly assume they don't need aggressive LDL-lowering therapy, similar to false reassurance from high HDL levels.

• Clinical imaging (such as cardiac CT to visualize coronary calcium and plaque burden) and measurement of Lipoprotein(a) are more clinically useful tools than particle size analysis for assessing cardiovascular risk.