#376 - AMA #78：长寿干预、运动、诊断筛查，以及管理高apoB、高血压、代谢健康等

嘿，大家好。

Hey, everyone.

欢迎收听Drive播客的抢先版问答环节（AMA）。

Welcome to a sneak peek ask me anything or AMA episode of the drive podcast.

我是你们的主持人，彼得·阿提亚。

I'm your host, Peter Attia.

在本短片的结尾，我会解释如何完整收听AMA剧集，以及我们为您准备的其他大量会员权益。

At the end of this short episode, I'll explain how you can access the AMA episodes in full along with a ton of other membership benefits we've created.

或者你现在就可以访问 peterattiamd.com/subscribe 了解更多信息。

Or you can learn more now by going to peterattiamd.com forward slash subscribe.

那么，不浪费时间了，以下是今天Ask Me Anything剧集的抢先版内容。

So without further delay, here's today's sneak peek of the Ask Me Anything episode.

欢迎收听Ask Me Anything AMA第78期。

Welcome to Ask Me Anything AMA episode 78.

在今天的AMA中，我们将回答一系列听众最常提出的各种问题。

In today's AMA, we take on a wide ranging mix of some of the most common listener questions.

从寿命干预和心血管风险，到禁食、血压管理、激素替代疗法、诊断筛查等。

From lifespan interventions and cardiovascular risk to fasting, blood pressure management, hormone replacement therapy, diagnostic screening and more.

这场对话较少涉及我们通常深入的研究，更多地聚焦于我如何在实践中、个人层面、临床层面，甚至某种程度上哲学层面思考这些议题。

This conversation is less about the deep research dives that we typically do and more about how I think through each of these topics in practice, personally, clinically and even somewhat philosophically.

因此，在本集中，我们将讨论延长寿命和健康寿命最重要的单一干预措施。

So in this episode we discuss the single most important intervention for extending life span and health span.

如何利用百岁运动员十项全能框架，激励中年人优先重视锻炼。

How to motivate midlife patients to prioritize training using the centenarian decathlon framework.

寿命与健康寿命之间的相互作用，以及为何将二者割裂是一种错误的二元对立。

The interplay between lifespan and health span and why separating them is a false dichotomy.

即使代谢健康状况完美，如何管理高水平的ApoB和胆固醇。

How to manage high APOB and cholesterol even with perfect metabolic health.

以及生物标志物，如零钙化评分、理想的血压目标、生活方式干预手段、何时使用药物治疗；如何在血红蛋白A1c检测之外评估和监测代谢健康，包括胰岛素、甘油三酯和二区输出；人们在改善健康时常见的错误，以及为何可持续的习惯优于短期高强度手段。

And biomarkers such as a zero calcium score, optimal blood pressure targets, lifestyle levers and when to use pharmacologic therapy, how to assess and monitor metabolic health beyond the hemoglobin A1C test including insulin, triglycerides and zone two output, Common mistakes people make when trying to improve health and why sustainable habits beat short term intensity.

当热量和蛋白质摄入受到控制时，限时进食和禁食的影响。

The effects of time restricted eating and fasting when calories and protein are controlled.

超加工食品的细微差别，从实际权衡到营养流失与热量密度的区别。

The nuances of ultra processed food from practical trade offs to the difference between nutrient loss and caloric density.

针对围绝经期和绝经期女性的激素替代疗法方法。

Approaches to hormone replacement therapy for women in perimenopause and menopause.

关于男性睾酮替代疗法的最新认识，包括风险、益处以及常见的误解。

The evolving understanding of testosterone replacement therapy in men, the risks, the benefits and certainly the misconceptions.

为什么我建议更早、更广泛的筛查和诊断，包括结肠镜检查、PSA、冠状动脉成像和低剂量CT肺癌筛查。

Why I recommend earlier and expanded screening and diagnostics including colonoscopy, PSA, coronary imaging and low dose CT for lung cancer.

全身MRI的优缺点。

The pros and cons of full body MRI.

我如何治疗糖尿病前期患者，针对睡眠、营养和运动进行个性化干预。

How I treat patients with prediabetes, tailoring interventions across sleep, nutrition and exercise.

为时间特别紧张的人设计的运动方案，包括力量训练和基于心率区的有氧运动。

Exercise programming for those who are especially time constrained, including strength and zone based cardio.

如何安全地为老年人引入高强度训练。

And how to safely introduce high intensity training to older adults.

如果你是订阅者，想要观看本播客的完整视频，可以在节目说明页面找到。

If you're a subscriber and want to watch the full video of this podcast, you can find it on the show notes page.

如果你不是订阅者，可以在我们的YouTube页面观看视频的抢先预览。

If you're not a subscriber, you can watch a sneak peek of the video on our YouTube page.

那么，不多说了，希望你们喜欢AMA第七十八期。

So without further delay, I hope you enjoy AMA seventy eight.

彼得，欢迎来到又一期AMA。

Peter, welcome to another AMA.

你最近怎么样？

How are doing?

很好。

Good.

谢谢你能再次邀请我。

Thanks for having me back.

很高兴我们的日程能协调一致，让你能来到这里。

I'm happy it worked with my schedule and your schedule for you to be here.

还有那个拳击T恤。

Also, like the boxing shirt.

今天对话中会提到拳击吗？

Any boxing that's gonna come up in the conversation today you think?

拳击对长寿不太有利，所以我不确定，但也不能完全排除。

Boxing's not that good for longevity, so I'm not sure but I wouldn't rule it out.

好的。

Okay.

好吧。

Alright.

也许我们可以把它当作一个阴阳平衡的回答。

Maybe we can use it as a yin yang kind of answer.

你可以控制你的APOB，或者选择挨些拳击，哪个可能更好呢？

You could manage your APOB or you could pick up some concussions which one might be better.

今天这一期会非常随机。

On that today is going to be a very random episode.

所以我们收集了听众关于各种不相关主题的问题，这里的重点将不再是深入探讨背后的科学，而是更多地关注你怎么做、你怎么想以及你个人和临床上的处理方式。

So what we did is we've been gathering questions from listeners on various topics all unrelated and the focus here will be much less a deep dive into the science behind it and much more what you do, how you think and how you approach things personally, clinically.

所以内容会更随意、更坦诚，我们只是把最近收集到的很多问题整合在一起。

So it's going to be a little more informal, a little more candid and we just combined a lot of questions we have recently.

因此我们将涵盖大量主题，包括治疗APOB、血压、代谢功能障碍、对限时进食和禁食的看法、超加工食品、激素替代疗法、睾酮、筛查与诊断、如果你是糖尿病前期该怎么办、当一个人时间非常紧张时你如何看待锻炼，等等。

So we're going to cover a huge variety of topics including treating APOB, blood pressure, metabolic dysfunction, thoughts on time restricted eating and fasting, ultra processed food, HRT, testosterone, screening and diagnostics, what to do if you're pre diabetic, how you think about exercising if someone's on a huge time crunch, and more.

所以我觉得这会是一场节奏轻松、略有不同的有趣对话。

So I think it should be a fun kind of little different pace.

但在我们开始之前，你还有什么想补充的吗？

But before we get rolling, anything you want to add?

我觉得没有了。

I don't think so.

我觉得你都讲全了。

I think you got it.

所以我才在这里啊。

That's why I'm here.

好吧。

Alright.

第一个问题。

So first question.

假设明天所有的寿命干预手段都消失了，只剩下一种。

Let's say tomorrow every lifespan intervention vanishes except for one.

如果你只能选择一种干预手段来延长寿命，对你来说不可妥协的是什么？

So if you can only do one intervention for lifespan, what is your non negotiable for you?

这是针对你个人，还是针对社会，还是

This is for me personally or for society or

这是个好问题。

It's a good question.

我们先说说你个人，然后再谈谈你的病人。

Let's get you personally and then your patients.

虽然你问的是关于寿命，但老实说，如果换成健康寿命，我的答案也不会有太大变化。

Well, you've worded the question for lifespan but honestly my answer doesn't change that much if you make it for lifespan and healthspan.

但如果你说的是寿命，健康寿命，答案就更加明显了。

Although if you say lifespan, healthspan, the answer becomes even more obvious.

那就是锻炼。

It would be exercise.

原因很简单。

And the reason is simple.

如果你看一下数据，我们目前所有的干预手段，包括戒烟、高血压管理、血脂管理、2型糖尿病控制，这些都对特定疾病或全因死亡率有显著影响。

If you simply look at the data, there's really no intervention we have including smoking cessation, management of hypertension, management of lipids, reduction of type two diabetes, all of those things have a significant impact on either disease specific or all cause mortality.

但当你观察心肺耐力、肌肉力量甚至肌肉质量时，其益处更大。

But when you look at cardiovascular fitness, when you look at muscular strength and even muscle mass, the benefits are greater.

而且，这里我们仅仅是从死亡率的角度来讨论。

And again, this is just talking about it through the lens of mortality.

所以，从寿命的角度来看，我认为答案是锻炼。

So, I think the answer from a lifespan perspective is exercise.

但同样，如果你扩展这个问题，不仅从寿命，还从健康寿命的角度来思考，那么答案就更加清晰了，因为对大多数人来说，生命最后十年生活质量的下降实际上是一个运动能力的问题。

But again, if you expand that and ask the question through the lens of not just lifespan but also health span, then I think it becomes even more clear because for most people, the reduction in quality of life in that final decade is actually a movement problem.

这是一个运动问题，是一个疼痛问题，也是一个体能问题。

It is a movement problem, it is a pain problem, it is a fitness problem.

而这正是我认为我们应该训练的目标。

And that's what I think we should be training for.

我们可以深入更多细节，但考虑到今天我们希望节奏快一点，我想我就说到这里。

There's more detail we could get into here but I think in the spirit of, I know we want to be a little quicker today, I'd probably just leave it at that.

有一个后续问题，你最后提到，生命末期的许多问题都源于肌肉质量下降和心肺功能减退。

One follow-up there, which is you kind of mentioned at the end a lot of what happens towards the end of life is a result of issues around muscle mass stability, cardiorespiratory fitness.

那么，你如何与三四十岁、五十岁左右的患者沟通，他们说：‘我现在想做什么都能做到，没有任何问题。’

So how do you talk to patients who are maybe in their 30s 40s 50s and they're like I can do everything I want to do now without issue.

我很忙，锻炼我知道很重要，但很难，我能以后再做吗？

I'm busy, exercise look I get it's important but it's hard, Can I kind of do it later?

当你想到自己晚年想做什么时，你如何鼓励人们现在就关注这些问题？

How do you encourage people to focus on this now when they think about what they want to do at the end of their life?

对他们来说，现在这样做非常容易。

It's very easy for them to do that currently.

是的。

Yeah.

我的意思是，我们开发了一个工具，将关于这个问题的思考和讨论从抽象层面转化为非常具体的对话。

I mean we've developed a tool to actually take the exercise of thinking about that and having that discussion from an abstract discussion into a very tangible discussion.

因此，无论患者的年龄如何，我们都会要求他们列出未来十年内最想实现的十项身体功能目标。

So what we do with our patients regardless of their age is force them to rank the 10 most important things to them physically that they want to be able to do in their last decade.

我们把这些目标称为‘百岁十项全能目标’。

We call those the centenary and decathlon goals.

其中一些目标只是我们所说的日常生活活动。

And some of these goals are just what we would call activities of daily living.

但我们希望人们能有抱负、有思考。

But we want people to be ambitious and be thoughtful.

所以，认真想想你真正想做的事情。

So, really think about what it is you'd want to do.

每一项活动都会被分解为动作模式和生理需求。

Each of those activities is deconstructed into movement patterns and physiologic requirements.

我们现在在这方面已经相当熟练了。

We've gotten pretty good at this now.

这花了好几年时间，才真正将这种艺术性的东西尽可能转化为科学方法。

This took a couple of years to really, really get down to as close as we could go from an art to a science.

然后，针对每一项活动，我们都会全面分析其运动需求、力量需求以及各项生理需求和参数。

And then for each of those activities, we look at the requirements, the movement requirements, the strength requirements, the physiologic requirements and parameters all across the board.

我们问：你想要打完18洞高尔夫并全程步行吗？

And we say, Okay, well, do you want to play 18 holes of golf and walk around?

要做到这些，你必须具备这些能力。

This is what you have to be able to do.

你希望能在这种地形上以每小时两英里的速度徒步一小时，这就需要你具备多少脚踝活动度、髋关节稳定性等等。

You want to be able to hike for an hour averaging a pace of two miles per hour on this type of terrain down to how much ankle movement you'd have to have, hip stability, etcetera, etcetera.

这些就是你必须具备的条件。

This is what you have to have.

然后，我们再逆向推算到每一个十年。

Then we project back by decade.

所以，在这个练习中，你唯一不知道的是一个人究竟会活到什么时候，但你应当有雄心壮志，假设我们现在在讨论，而你已经90岁了。

So, the only thing you don't know in this exercise is exactly when someone is going to live to, but you want to be ambitious and say, Let's assume we're having this discussion and you're 90 years old.

如果你希望在90岁时还能做到这些事，那么在80岁时，你就必须好上这么多。

If you're gonna be able to do those things at 90, at 80, you have to be this much better.

在70岁时，你必须再好上这么多。

And at 70, you have to be this much better.

在60岁时，也要好上这么多。

And at 60, this much better.

我们就这样一路回推，直到你当前的年龄，比如30岁或40岁。

And we back that all the way up until where you are at say 30 or 40.

然后，我们现在就拿你当前的状态去对照这些目标。

And then we measure you against those things right now.

结果发现，几乎毫无例外，一个人当前的状态与为了顺利应对未来走向90岁所必需达到的水平之间，存在着巨大差距。

And lo and behold, almost without exception, there is a big gap between where a person is today and where they need to be today in order to take that gravitational slide down to where they're going to be at 90.

对我来说，这是进行这场对话最有力的方式，因为它不再那么抽象了。

For me, that is the most potent way to have this discussion because it's not as abstract anymore.

现在他们可以看清了，哦天哪，即使我现在能做到，但考虑到衰退率，我将来会不够用。

Now they've sort of can look and see, oh gosh, even though I can do it now, when I bake in the rate of decline, I'm not going to be sufficient.

换句话说，就像说一样：即使你退休当天银行里的钱比你需要的多，也不意味着你在退休两年或十年后仍有足够资金，因为你必须考虑不再赚钱后会花掉多少钱。

In other words, sort of like saying like, look, just because you have more money in the bank today than you will need at retirement on the day you retire, It doesn't mean you will have enough two years or ten years after retirement because you have to account for how much money you're going to spend when you're no longer making money.

要深入探讨具体如何操作，那就超出了任何播客的范围。

Getting into all the details of how that is done, it would be beyond the scope of any podcast.

但我认为宏观上的要点是：开始锻炼永远不早，但要实现所有目标却可能太晚。

But I think the macro point is it's never too early to start training but it can be too late to hit all of your goals.

开始锻炼永远不晚，但如果你80岁时什么也做不了，想在90岁时滑雪就很难了。

Never too late to start training but if you show up at 80 unable to do anything, it's gonna be hard to be skiing at 90.

但如果你想在90岁时滑雪，那最好从30岁就开始考虑，以便逐步积累这些益处。

But if you want to ski at 90, the time to think about it is when you're 30 and so that you can kind of compound those benefits.

你之前提到的另一件事，也是我们经常被问到的问题，是你对寿命和健康寿命的回答。

Another thing you said earlier, which is something that we get a lot of questions on is you were talking about your answer for lifespan and your answer for healthspan.

在那种情况下，两者的答案非常相似。

In that case, it was very similar for both.

但人们经常谈论针对寿命的干预措施。

But oftentimes you hear people talk about doing interventions for lifespan.

其他人则非常关注针对健康寿命的干预，有时甚至以牺牲寿命为代价。

Other people really focus on doing interventions for healthspan sometimes at the expense of lifespan.

那么，你如何调和寿命与健康寿命这两个概念呢？

And so how do you kind of reconcile the two concepts to you of lifespan, healthspan?

我认为把它们分开是一种虚假的二元对立。

I think it's a bit of a false dichotomy to separate them.

事实上，人们其实两者都想要。

The truth of the matter is people actually want both.

当我听到有人说，我不在乎能活多久，我只希望生活质量更好，我理解他们的意思，我认为这其实是简略地表达：我不想在健康状况持续衰退中变老。

When I hear people say, I don't care about how long I live, I just want to live a better quality of life, I understand what they're saying and I think that's sort of shorthand for I don't want to get old in a declining state of health.

这完全合理。

Totally reasonable.

但如果我们坦诚一点，我认为我们所有人都希望活得更久，前提是能活得更好。

But if we're being honest, I think all of us would love to live longer provided we can live better.

好消息是，大多数你为延长健康寿命所做的事情，也会提升整体寿命。

And the good news is most of the things that you do to pursue health span will also improve lifespan.

如果你以正确的方式关注，反过来也是如此。

The reverse is true if you focus on it the right way.

所以，我来详细说明一下。

So, I'll elaborate.

我专门写了一整章关于如何活得更久。

And I devoted an entire chapter about outlive.

我认为第四章专门阐述了这个观点：你可以采取两种策略来延长寿命。

I think chapter four is dedicated to making this point which is you could take two strategies to approach lifespan elongation.

一种策略是，找出在患有慢性病的情况下如何活得更久的方法。

One strategy might be, let's figure out ways to live longer with chronic disease.

顺便说一句，这正是当今广泛采用的策略。

By the way, that is the strategy that is largely employed today.

这就是医学2.0策略。

That's the Medicine two point zero Strategy.

我再次解释了为什么这是该策略的原因和背景。

Again, I explain the context of why that's the strategy and why.

我认为，在不加评判的情况下，我解释了为什么基于医学2.0的成功，这是一个合理的结论。

I think without assigning judgment, I explain why that's a reasonable conclusion based successes of Medicine two point zero.

但我认为，这并不是延长寿命的好策略。

But what I argue is, I don't think that's a great strategy for longevity.

我认为，对于长寿而言，正确的策略是：如何在没有慢性疾病的情况下活得更久，从而延长无慢性疾病的生活阶段？

I think for longevity, this right strategy is how can I live longer without chronic disease and therefore elongate the period of life that I am free of chronic disease?

如果这就是你追求延长寿命的方式，那么你同时也获得了健康寿命。

And I think if that's your pursuit of lifespan elongation, you're also getting health span.

因此，总结来说，我认为对于你所能想到的每一种干预措施——无论是运动、营养、睡眠还是药物——当你以这些方式追求寿命或健康寿命时。

So, I guess in summary there, I would say with every intervention that you can think of, whether it's exercise, nutrition, sleep, pharmacology, whether you're pursuing lifespan or healthspan with these things.

当然，你通常同时追求两者。

And of course, you're often pursuing both concurrently.

如果你通过延缓慢性疾病发病来追求寿命，你就能获得健康寿命的益处。

If you're pursuing lifespan through the lens of delaying the onset of chronic disease, you're getting healthspan benefits.

如果你追求健康寿命只是为了健康寿命本身，并且你采用的是一个合理的定义，那么我们可以就此讨论一下，你将会获得健康寿命的益处。

If you're pursuing health span for the sake of health span and you're doing it at least through a reasonable definition, we can maybe talk about that, you're going to be getting health span benefits.

那么，现在让我们从这些目标何时产生矛盾的角度来提问。

So, let's now ask the question through the lens of when are these at odds?

好的。

Okay.

如果我定义健康寿命——顺便说一下，这是主观的，我并不想暗示我的健康寿命定义是唯一正确的定义。

Well, if I define health span, which by the way is subjective, I don't want to suggest that my definition of health span is the right definition.

这只是让我和我的患者产生共鸣的定义，它包含身体、认知和情感三个层面。

It's just the one that resonates with me and frankly with my patients, which is it has a physical, cognitive and emotional component.

但这个身体层面并不是极端的。

But the physical component is not extreme.

我的身体层面并不是说我想赢得CrossFit比赛。

The physical component isn't that I want to win the CrossFit games.

我并不是要贬低CrossFit比赛，我只是用它作为一个例子，因为大家都明白它的含义。

And I'm not here to dunk on the CrossFit games, I just use that as an example because everybody understands what it means.

但如果有人表示，对我来说唯一重要的是成为世界CrossFit冠军或世界上最优秀的MMA选手，这确实是一项非凡的体能任务。

But if an individual said, look, the only thing that matters to me is to be the CrossFit champion of the world or to be the world's best MMA fighter, I mean, that's a remarkable physical task.

但在这一层次上，你实际上可能正在违背自己长期的健康利益，尤其是在身体健康和受伤风险方面。

But at that level, you might actually be working against your long term interests in terms of health, at least in physical health and injury.

因此，任何健康寿命的优化都必须考虑：这种做法是否会给我的晚年带来我无法承受的风险，无论是头部创伤还是严重的骨科风险。

So, every health span optimization must also be viewed through the lens of does this carry much more risk than I want for later in life, whether it be through head trauma or whether it be through significant orthopedic risk.

你这么早就把拳击和答案联系起来，真是绝妙，点赞。

That was a great way to tie in boxing to an answer really early on, so props on that.

接下来我得问个跟进的问题。

A follow-up just because I have to.

你现在这个年纪，你觉得你更有可能做到哪一项？

Your age right now, what do you think you'd have a better chance at?

在你这个年龄段成为CrossFit冠军，还是赢得办公室国际象棋锦标赛？

Becoming a CrossFit champion in your age bracket or winning the in house chess tournament?

毫无疑问，赢得办公室国际象棋锦标赛。

Undoubtedly winning the in house chess tournament.

很好。

That's good.

知道这个很好。

That's good to know.

所以，给那些CrossFit爱好者们点个赞。

So that's some shout out to CrossFitters out there.

不过，你指的是家里比赛里那三四个固定的人吧？

You're talking about just the same three or four people in the in house tournament though, right?

就像我们并没有引进其他人。

Like it's not like we're bringing in or anything.

我说的是你和孩子们一起玩的时候。

I'm talking the children you play with.

是的。

Yes.

所以甚至都不是成年人。

So not even adults.

好的。

Okay.

公平。

Fair.

小孩子。

The young kids.

好吧。

Alright.

这个我知道了。

That's good to know.

下一个问题。

Next question.

我们经常被问到的问题是，假设有一个40岁的人来找你，他身体状况不错。

Question we actually get a lot which is let's say you have someone, 40 year old coming to you, They are in shape.

没有胰岛素方面的问题。

No issues with insulin.

代谢上非常健康。

Metabolically very healthy.

他们做了些实验室检查，发现APOB或LDL非常高，但CAC评分为零。

They get some lab work done and they have a very high ABO B or LDL but they have a zero CAC score.

所以他们做了CAC检查，结果是零。

So they got a CAC done zero.

同样是40岁。

Again, 40 years old.

所以当你从患者的角度思考时，你会治疗他们的APOB吗？

So when you're thinking about this, let's say from a patient perspective, are you treating their APOB?

你会信任他们高水准的体能、良好的VO2最大值和代谢健康状况吗？

Are you trusting their high level fitness, good VO2 max, metabolically healthiness?

首先，我很喜欢见到这样的患者，因为最难改善的问题，恰恰是这个人已经具备的良好状态。

Well first of all, I love seeing a patient like this because the hardest things to fix are the things that this person is already showing up with in great shape.

我并不是不喜欢解决或尝试解决困难的问题，但就这个人而言，能以这样的状态前来就诊真是太好了。

And it's not that I don't love fixing or trying to fix the hard stuff but for the sake of this person, this is a great place to show up.

因为高水平的心肺耐力和胰岛素敏感性绝对能保护人体，不仅对抗动脉粥样硬化性心血管疾病，还对抗所有慢性疾病。

Because high cardiorespiratory fitness, insulin sensitivity are absolutely protective against not just ASCVD but all chronic diseases.

但问题是，它们并不能完全抵消ApoB在动脉粥样硬化中的作用。

The problem is they don't neutralize completely the role of ApoB in atherosclerosis.

不幸的是，全国各地以及全球的墓地里，都埋葬着许多ApoB水平很高、却没有任何其他风险因素（包括高血压）的人，他们依然发展出动脉粥样硬化性心血管疾病并过早死亡。

And the unfortunate reality of this is that the graveyards across this country and around the world are littered with people who have high ApoB, otherwise don't have risk factors including hypertension and yet develop ASCVD and can die prematurely.

但这并不是大多数人的状况。

That's not the majority of people.

大多数因动脉粥样硬化性心血管疾病过早死亡的人，都具有多个风险因素。

The majority of people who are dying prematurely of ASCVD have multiple risk factors.

现在，ApoB颗粒是斑块形成的直接驱动因素，因此每一个LDL颗粒都可能是潜在的斑块种子，无论代谢健康状况如何。

Now, ApoB particles are the proximate driver of the atheroma and therefore every LDL particle is a potential seed regardless of metabolic health.

还值得一提的是，钙化评分为零意味着大约有15%的假阴性风险。

It's also worth pointing out a zero calcium score carries with it an approximate fifteen percent risk of being a false negative.

我本人亲眼见过大约十例钙化评分为零但实际上并非零的情况。

I've personally seen, I don't know, ten cases of zero calcium scores that are not zero.

不超过这么多。

No more than that.

天啊。

Gosh.

如果我认真回想一下，过去两年里可能有十例，如果我回溯得更久一些的话。

If I really stopped to think about it, would be 10 over the last two years if I go back and look longer.

有人冠状动脉钙化评分为零，但不久后做了CT血管造影，我们确实发现了软斑块。

Where a person has a zero calcium score but shortly thereafter a CTA is done and we do indeed see soft plaque.

这意味着确实存在一些进展中的疾病。

Which means that there really is some advancing disease.

因此，我在这里将这种情况排除，但我还要更进一步，尼克，我直接假设这个人CTA检查结果完全正常。

So, I carve that out here but I'm gonna one up you, Nick, and just assume this person has a perfect CTA.

让我们假设你已经完成了所有先进的检测，应用了可以叠加在CT扫描上的算法，并且你非常非常确信这个人冠状动脉状态极佳。

And let's just assume that you've done all of the advanced testing, you've applied the algorithms that can be layered on the CT scan and you're really, really confident this person has pristine coronary arteries.

那么现在的问题是，你应该怎么做？

So now the question is what should you do?

这归根结底是一个关于因果关系的根本问题。

Well, it all comes down to a fundamental question of causality.

我们是否相信ApoB与ASCVD有因果关系？

Do we believe ApoB is causally related to ASCVD?

我在这里不会详细讨论这个问题，因为我已经多次讲过了。

I'm not going to address that in detail here because I've done so many many times.

答案是明确无误的。

And the answer is unambiguous.

这是生物学中为数不多的毫无歧义的事情之一。

This is one of the few things in biology where there just isn't ambiguity.

就像生物学中任何事情都可能存在一些歧义一样，我想明确的是，甚至物理学中也必须存在一些歧义。

As much as anything can be unambiguous in biology, I wanna be clear, there has to be some ambiguity in even physics.

所以，如果你相信ApoB是致病因素，那么你就应该进行治疗，无论其他情况如何。

So, if you believe that ApoB is causal, then you treat it regardless.

当然，你可能不会那么激进地治疗。

Now, maybe you don't treat it as aggressively.

因此，如果一个人的载脂蛋白B水平为150，那么对他们来说，一个合理的目标可能是60；但如果这个人载脂蛋白B也是150，但冠状动脉已经布满斑块，那么目标就应该是30。

So, if this person shows up with an APO B of 150, maybe a reasonable goal for them is 60 versus if this person shows up with an APO B of 150 and they have coronary arteries that are littered with plaque at which point the goal is 30.

所以，再次强调，有不同的方法和不同的治疗强度。

So again, there's different ways and different degrees of aggressiveness.

但你治疗因果性危险因素的原因，并不是因为你确信这个人一定会患上ASCVD，而是因为你明白，通过干预因果因素，可以降低风险。

But the reason you treat causal risk factors is not because you are sure that this person is going to get ASCVD but because you understand that by treating something that's causal, you reduce the risk.

我过去曾举过这个例子，现在再举一次：尼克，我有一个40岁的人，胰岛素敏感，非常健康，一切指标都很好，但他们上个月刚开始吸烟，现在来我这里就诊。

And again, the example I've given in the past and I'll give again is, Nick, I have a 40 year old person who's insulin sensitive, super healthy, everything about them looks great and they just started smoking last month and they're in my office.

假设我为他们做了世界上最高精度的肺部扫描。

Let's just assume I did the most high fidelity lung scan in the world.

他们目前没有任何肺癌或慢性阻塞性肺病的证据。

They don't have any evidence of lung cancer or COPD for that matter.

我应该劝他们戒烟，还是应该说：‘没关系，继续吸烟吧，等我们看到肺癌迹象时再戒也不迟。’

Should I encourage them to stop smoking or should I say, Look, it's okay to keep smoking but the moment we start to see evidence of lung cancer, we're going to stop.

当然，这里的答案显而易见。

Of course, the answer was obvious here.

没有人会不同意。

Nobody would disagree.

我们会立即让这个人戒烟。

We would get that person to stop smoking immediately.

并不是因为我确定如果他们继续吸烟，就一定会得肺癌。

Not because I know for certain that if they keep smoking, they will get lung cancer.

许多吸烟者并不会发展成肺癌。

Many smokers do not go on to get lung cancer.

顺便说一下，有百分之十五的肺癌患者从未吸烟。

And by the way, fifteen percent of people who get lung cancer have never smoked.

但吸烟与肺癌之间仍然存在因果关系，这正是我们要求这个人立即戒烟的原因。

But there is still causality between smoking and lung cancer and that's of course why we would tell this person to stop smoking immediately.

我们经常遇到另一个问题，就是血压，高血压。

Another question we see come through a lot, blood pressure, high blood pressure.

显然，我们已经讨论了很多关于高血压如何成为沉默杀手的问题，在你看来，普通人应该将血压控制在什么目标水平？

Obviously we've talked a lot about how high blood pressure can be a silent killer and in your view what do you want the average person's target blood pressure to be?

假设有人来找你，他们的血压高于这个标准，他们可以采取哪些最具影响力的方法来降低血压？

And let's say someone comes to you and it's higher than that, what are some of the highest impact levers they can have to lower their blood pressure?

感谢您收听《The Drive》今天的AMA预览集。

Thank you for listening to today's sneak peek AMA episode of The Drive.

如果您想收听这次AMA的完整版，您需要成为高级会员。

If you're interested in hearing the complete version of this AMA, you'll want to become a premium member.

对我来说，提供所有这些内容而不依赖付费广告至关重要。

It's extremely important to me to provide all of this content without relying on paid ads.

为此，我们的工作完全依赖于会员的支持。

To do this, our work is made entirely possible by our members.

作为回报，我们提供仅限会员的独家内容和福利，远超免费内容。

And in return, we offer exclusive member only content and benefits above and beyond what is available for free.

因此，如果您想将您对这一领域的认知提升到下一个层次，我们的目标是确保会员获得的回报远超订阅费用。

So if you wanna take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription.

高级会员包含多项福利。

Premium membership includes several benefits.

首先，提供详尽的播客节目笔记，涵盖我们每期讨论的每一个主题、论文、人物和相关内容。

First, comprehensive podcast show notes that detail every topic, paper, person, and thing that we discuss in each episode.

而且据外界传言，没有人能比得上我们的节目笔记的深度。

And the word on the street is nobody's show notes rival hours.

其次，每月一次的问答（AMA）节目。

Second, monthly ask me anything or AMA episodes.

这些节目由对订阅者问题的详细回答组成，通常聚焦于单一主题，旨在为会员特别关注的话题提供充分的清晰度和细节。

These episodes are comprised of detailed responses to subscriber questions typically focused on a single topic and are designed to offer a great deal of clarity and detail on topics of special interest to our members.

当然，您还能获得这些节目的节目笔记。

You'll also get access to the show notes for these episodes, of course.

第三，获取由我们专职研究分析团队制作的高级通讯。

Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts.

这份通讯涵盖与长寿相关的广泛主题，内容比我们的免费周报更加详尽。

This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter.

第四，访问我们的私人播客源，让您能够收听所有节目，包括不含您现在所听的这段宣传语的AMA节目，且与您常规播客源中的内容分离。

Fourth, access to our private podcast feed that provides you with access to every episode including AMA's sans the spiel you're listening to now and in your regular podcast feed.

第五，QALYs，这是我们为会员特别制作的另一个专属播客，精选了《驱动》过往各期的精彩片段。

Fifth, the QALYs, an additional member only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of the drive.

这是在不需逐个回听所有过往集数的情况下，快速了解之前内容的好方法。

This is a great way to catch up on previous episodes without having to go back and listen to each one of them.

最后，还有一些陆续增加的其他福利。

And finally, other benefits that are added along the way.

如果你想了解更多并获取这些会员专属福利，请前往 peterateyamd.com/subscribe。

If you want to learn more and access these member only benefits, you can head over to peterateyamd.com forward slash subscribe.

你也可以在 YouTube、Instagram 和 Twitter 上关注我，我的用户名都是 PeterAtyiaMD。

You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAtyiaMD.

你也可以在 Apple Podcasts 或你使用的任何播客平台为我们留下评价。

You can also leave us a review on Apple Podcasts or whatever podcast player you use.

本播客仅用于一般信息目的，不构成医学、护理或其他专业医疗服务，包括医疗建议的提供。

This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice.

不会形成医患关系。

No doctor patient relationship is formed.

使用本信息及本播客链接的材料，用户需自行承担风险。

The use of this information and the materials linked to this podcast is at the user's own risk.

本播客的内容不应用于替代专业的医疗建议、诊断或治疗。

The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

用户不应忽视或延迟针对自身健康状况寻求医疗建议，应向其医疗专业人员寻求帮助。

Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions.

最后，我非常重视所有利益冲突问题。

Finally, I take all conflicts of interest very seriously.

关于我所有的披露事项以及我投资或咨询的公司，请访问 peterateamd.com/about，那里有我更新并活跃的全部披露清单。

For all of my disclosures and the companies I invest in or advise, please visit peterateamd.com/ about where I keep an up to date and active list of all disclosures.