Welcome to CardioNow, the podcast that helps you stay ahead of heart disease with clarity, not confusion. In today’s episode, Dr. Mahesh Mulumudi dives into one of the most misunderstood areas of cardiovascular health: cholesterol. While most of us track our cholesterol numbers, are we really paying attention to what matters the most? Join us as Dr. Mulumudi, an interventional cardiologist and founder of CardioNow, breaks down why simply knowing your LDL isn’t enough, how the size and number of cholesterol particles change your risk, and the surprising role that genetics, metabolism, and even lifestyle choices like carb intake play in heart disease. From particle counts to cutting-edge tests and actionable advice, we’ll cut through the noise to help you truly understand cholesterol and make smarter choices for your heart.
Timestamps:
00:00 Understanding cholesterol measurement basics
05:27 Understanding cholesterol and heart disease
08:57 Understanding lipoprotein A risks
12:04 Impact of carbs on cholesterol
15:18 Understanding cholesterol and inflammatory markers
17:30 End of episode goodbye
Cholesterol: Why It’s More Than Just a Number (Insights from CardioNow Podcast)
Understanding cholesterol can feel confusing, but the latest episode of CardioNow offers a fresh perspective that clears up common myths and goes beyond the typical cholesterol numbers. Interventional cardiologist Dr. Mahesh Mulumudi provides practical advice and essential knowledge for anyone serious about heart health.
The Limitations of Standard Cholesterol Testing
Most clinics and labs check your cholesterol by measuring total cholesterol, LDL (bad cholesterol), HDL (good cholesterol), and triglycerides. As Dr. Mahesh Mulumudi points out, these values are measured in milligrams per deciliter and are helpful, but they do not tell the whole story. For years, LDL has been the focus because studies like the Framingham Study showed a strong link between LDL and heart disease. But just having a “normal” LDL does not guarantee you’re out of the risk zone.
The Real Risk: LDL Particle Number and Size
What matters even more than total LDL is the number and size of LDL particles circulating in your bloodstream. Dr. Mahesh Mulumudi explains that LDL particle number is a much better indicator of your risk for atherosclerosis (plaque buildup in the arteries). Ideally, you want fewer than 1000 LDL particles, and the particles should be large and fluffy. Think cotton balls, not dense bullets. Small, dense LDL particles are more likely to slip into artery walls and contribute to plaque formation.
Beyond LDL: The Role of Lipoprotein(a) in Heart Disease
While standard cholesterol tests provide important metrics, Dr. Mahesh Mulumudi brings attention to lipoprotein(a), sometimes called LP(a). This is a genetically determined molecule, and having high levels of LP(a) is an independent risk factor for heart disease; it runs in families and is especially sticky, making it great at sticking to artery walls and kickstarting plaque. Most people have never heard of it, but Dr. Mahesh Mulumudi recommends that everyone should get checked for LP(a) at least once, especially after major life or metabolic changes like menopause, diabetes, or serious illness.
Can You Change Your Lipoprotein(a) Level?
Right now, there are no specific medications or lifestyle changes that can directly lower LP(a). If your levels are high, don’t panic. Work with your physician to optimize all your other cholesterol and inflammatory markers. Tighten up your LDL goals even more, lower is better if you have high LP(a).
Lifestyle Tips To Improve Cholesterol Profile
Improving cholesterol isn’t just about cutting fat. In fact, Dr. Mahesh Mulumudi emphasizes the power of carbohydrate management. Excess carbs spike glucose and insulin, both of which are linked to higher LDL particle numbers and smaller, riskier particle size.
He also shares an easy tip: after every meal or snack, take a short walk for five to ten minutes. This habit blunts glucose and insulin spikes and positively influences LDL particle profile. Building activity into your routine and cutting carb peaks may matter more than stressing over saturated vs. unsaturated fats. Still, for those who want to refine their diets, plant-based fats from nuts and avocados can encourage larger, safer LDL particles.
Apple Cider Vinegar: A Surprising Helper
If you are inclined, try mixing a tablespoon of apple cider vinegar in water and drinking it with meals. There is evidence that this practice can help reduce glucose spikes after eating, according to Dr. Mahesh Mulumudi. If you already use it, you may be supporting your heart health without realizing it.
Going Beyond Basic Cholesterol Tests
Advanced cholesterol panels now measure both particle number and size for LDL, HDL, and VLDL, providing a much clearer window into your cardiovascular risk. In addition, newer tests like Glyca and LP-PLA2 assess inflammation, not just cholesterol, offering a more complete picture of your heart health, as noted.
Key Takeaway
Cholesterol is more than just a number. To truly understand your heart risk, look beyond LDL and total cholesterol. Get particle numbers and sizes measured, have LP(a) checked at least once, and ask about inflammatory markers. Manage carb intake, get moving after meals, and consider adding apple cider vinegar as a small daily habit. For more heart health clarity, catch every episode of CardioNow, your trusted resource for evidence-based prevention and real-world strategies.
Dr. Mahesh Mulumudi LinkedIn - https://www.linkedin.com/in/mahesh-mulumudi-1ba8733
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TopHealth Media Network - https://tophealth.care/
Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”
[00:00:00] Majority of the Clinics and Laboratories that check the Cholesterol levels will give us Cholesterol numbers as Total Cholesterol. It is an important marker. But the question is, if you have a normal LDL, is that the right measure? Can we stop there or do we need to go something beyond? I want to focus on the concept of particulate matter that are more important to identify the atherogenic risk.
[00:00:24] For example, LDL comes as a concentration. So you must have seen your LDL as 120 mg per deciliter or 160 mg per deciliter or 190 mg per deciliter. It's only a tip of the iceberg. It doesn't tell you the entire story. The story behind LDL's ability to cause atherosclerotic plaque is based on a number of LDL particles. There are technologies now and there are several labs that measure these particles.
[00:00:49] Besides the LDL particles, if you think about the particle size, it's also an important fact.
[00:01:18] Welcome back to CardioNow, the podcast that helps you stay ahead of heart disease with clarity, not confusion. Today we're tackling one of the most misunderstood topics in cardiovascular health, cholesterol. Most people think they know their numbers, but what if the numbers you're tracking aren't telling the full story? So Dr. Mahesh Mulumudi, interventional cardiologist and founder of CardioNow is here to break down what really matters when it comes to cholesterol risk and protecting your heart. So it's nice to see you again. How are you doing today? Doing really well. And it's so nice to be here again.
[00:01:48] It's an important topic you brought up. It bridges what we talked last time about the risk of heart disease in young people and what should we do to identify the heart disease in these folks. And in this episode, possibly we can focus on what does cholesterol check really mean? What are we really checking for and what should we be checking for? I think a lot of people feel like they're good if their LDL is normal, but that's not always the case, is it?
[00:02:17] No, it is not. Majority of the clinics and laboratories that check the cholesterol levels will give us cholesterol numbers as total cholesterol, LDL, the so-called bad cholesterol, HDL, which is kind of a protective measure, and triglycerides. If you look at the different components of the cholesterol itself, it is given as a concentration, milligrams per deciliter.
[00:02:42] The concentration of cholesterol served its purpose. Yes, it is an important marker. It had its time and we were able to identify what to measure, what to target, and how we can reduce it to lower numbers to reduce your heart disease. But the question is, if you have a normal LDL, is that the right measure? Can we stop there or do we need to go something beyond?
[00:03:04] I want to focus on the concept of particulate matter, the particles, the cholesterol particles that are more important to identify the atherogenic risk, meaning their ability to form plaque. And it compares to cholesterol concentration that's given as a milligram per deciliter. The particles are more indicative of atherogenic risk. So I'll tell you, for example, LDL comes as a concentration.
[00:03:29] So you must have seen your LDL as 120 milligram per deciliter or 160 milligram per deciliter or 190 milligrams per deciliter. It's only a tip of the iceberg. It doesn't tell you the entire story. The story behind LDL's ability to cause atherosclerotic plaque is based on the number of LDL particles, a bit more correlated to that than the LDL concentration as milligrams per deciliter.
[00:03:54] There are technologies now and there are several labs that measure these particles in the cholesterol, in the bloodstream. The cholesterol particles will give you the number of LDL particles that we have. Number of LDL particles is generally considered optimal if it is less than 1000 particles. And besides the LDL particles, if you think about the particle size, it's also an important fact. Yes, it's slightly less important as compared to the total number of LDL particles
[00:04:22] when taken into consideration as a total number. But LDL particles, you need to have them low and you need to have the right kind of LDL particles. When I'm talking about right kind of LDL particles, LDL particles also are measured in these tests, the size of them. For example, LDL particles' size should be more than 20.5 nanometers. So there are small LDL particles, there are large LDL particles. You want your LDL particles to be large.
[00:04:50] The way I try to remember them and I try to describe them is they're like cotton balls. They're soft and fluffy and they are in a way benign. If you look at the smaller LDL particles, they're dense. I think of them as bullets. They can enter the cells, start the plaque formation and create the atherosclerotic plaque in the arteries, heart, neck arteries and anywhere else in the body. And speaking about LDLs, let's pause for a second and maybe start with the basics a little bit.
[00:05:19] Can you explain what is LDL really? And it's been the focus for so long, but why do you think it has been the focus for so long? Traditionally, when cholesterol was considered a risk factor for heart disease, majority of the studies came from Framingham study, Massachusetts. That's where they all come from. And initially it was a total cholesterol that was correlated with heart attacks and heart disease. Higher the cholesterol, higher the heart attack.
[00:05:45] It got further refined by measuring the density of these particles. So LDL is low-density lipoproteins and HDL is high-density lipids and triglycerides and total cholesterol. So if you take these independent components of the cholesterol and try to correlate, one type of cholesterol, that cholesterol component that has the highest correlation with coronary artery disease is LDL.
[00:06:12] That's why LDL became the prime molecules or component of the cholesterol that was heavily correlated with coronary disease and was considered the major risk factor for heart disease. And why do you think that cholesterol is so confusing for a lot of patients? A lot of the misconceptions about cholesterol is we think cholesterol comes from what we eat. So we eat less cholesterol or low cholesterol that's going to lead to lower cholesterol and a healthy living. It is not that simple.
[00:06:42] Cholesterol is largely controlled by our internal metabolism. How we process the lipids? How do we create? We create the cholesterol in the body. So we absorb fat inside the body and then that gets converted to different forms of cholesterol. So our metabolism plays a significant role in what kind of cholesterol we have. Good cholesterol, bad cholesterol and so on. So it's very essential for us to understand the fact it's not just the question of eating the right kind of fat.
[00:07:11] Internal metabolism plays a significant role in what kind of cholesterol we have. And you've touched on this a little previously, but I believe you've mentioned that not all LDL is equal. So what does that mean? Can you explain that a little bit? That's what I meant by the LDL particles. If somebody has a normal LDL concentration, but they can have high number of LDL particles in the blood, high number of LDL particles is equal to higher instance of atherosclerosis.
[00:07:37] So they may also have normal LDL or lower LDL. They may have abnormal lipoproteins like lipoprotein A that is identified as an independent risk factor. It's a genetic marker we are born with. So it's better to check the lipoprotein A at least once in our lifetime to understand that we have a high lipoprotein A or low lipoprotein A. Let's talk a little bit about lipoprotein A and LPA. LPA, they call it, yes.
[00:08:05] So most people have never heard of it, including myself. I know I'm not familiar with it. So what is it exactly? So every LDL particle is wrapped by an apoprotein and there are some particles that are wrapped by a lipoprotein A and it's a different type of the lipoprotein A that is a little bit more sticky to the intercellular junctions, meaning it sticks to the intercellular junctions like between the cells or the linings of the heart arteries
[00:08:34] or arteries of the brain and so on. And it sticks there, oxidizes and penetrates and initiates the plaque formation. So lipoprotein A is a bit more atherogenic compared to normal LDL and it runs in the family. So it's better to check the lipoprotein A at least one time. Okay. And why is LPA such a big deal when it comes to prevention specifically? It's not that it's the only one that we need to focus on, but that has been the ignored factor for a long time.
[00:09:04] And we need to bring it back into focus saying that we need to check out lipoprotein A. Suppose somebody has a normal LDL, a normal cholesterol, and that doesn't mean that we got it all made well for us and I'm going to be healthy. And if you have a high lipoprotein A, that itself is a plaque forming and independent risk factor. And so it is better to know the lipoprotein A levels for all of us. There are no real treatments for lipoprotein A. That's a challenge we have right now.
[00:09:32] They are in development, they're in trials, but there is no medication for lipoprotein A. So if somebody has a high lipoprotein A, what can you do? You can modify other lipids. We cannot change the lipo A, but we need to modify the other lipids. So your LDL goals will change. Your LDL goal will be tighter and lower. That's what I will aim for my patients when they have a high lipo A because I cannot do much about the lipo A. And that's a genetic marker. There are no medications for it.
[00:10:03] There are no lifestyle modifications that can change it. But I can guide my patients to reduce the other components, meaning LDL, towards lower levels and reduce the risk of heart disease. And it sounds like everyone should probably get tested for LPA at some point, but who should actually get tested for LPA and how often should they be tested? Everyone should get tested once, minimum once to start.
[00:10:29] If they have a high lipoprotein A, although it's a genetically determined molecule, that doesn't mean that you'll have the constant number throughout your lifetime. Major metabolic changes in the body will change the lipo A levels. So I'm going to give my opinion, not based on complete evidence on this one, is to check the lipo A ones. Check the lipo A whenever there is a major change in your metabolism. So you become diabetic, you become postmenopausal.
[00:10:58] You had, for example, a viral illness that made you pretty sick and you went on hormone replacement therapy. Any of the changes in the metabolism or a serious illness will affect or can affect lipo A levels. Let's say if someone finds out that they have a high LPA, what can they actually do about it right away? The first thing to do is definitely speak with your physician about having lipids checked and lipid particles checked.
[00:11:26] So you have a better idea what your LDL is, what your LDL particles are, LDL particle size is. Remember that we cannot modify lipo A with the current therapies that we got out there. There's no real therapy for lipo A, but we can modify the other components of the cholesterol into an optimal state, meaning reduce your LDL particles, make the particles as large as we can. How can we go about doing that is by modifying the lifestyle.
[00:11:51] And lifestyle is a broad term, but I definitely want to focus on utilizing a proper diet to influence the number of LDL particles and the particle sizes. One of the biggest driver of LDL particle numbers and particle sizes, besides the fat intake, it is actually the carbon intake. Carbon intake drives the LDL size quite a bit.
[00:12:17] And reducing the glucose peaks and reducing the insulin peaks associated with the high glucose levels can definitely modify the LDL particle number and particle size. I'm a big proponent of exercising immediately after eating. And after every meal and every snack, if you can go out and walk, you don't have to go out. Even if you go up and down the stairs in your house or walk around the house for five or ten minutes after eating,
[00:12:46] will blunt the peaks, reduce the peak peaks of glucose, reduce the insulin peaks that are associated with the glucose peaks typically, thereby modify the cholesterol molecules in a favorable manner. The other one that I want to say about lifestyle is people talk about should I be eating animal fat or vegetable fat or should I be eating polyunsaturated fats or saturated fats. It is not about the kind of fat.
[00:13:16] Kind of fat is important. It's not the only factor you have to figure out. If somebody is metabolically active, they are in a good position to eat a bit more saturated fat compared to people that are not so metabolically active. So think of it like that. And then the other factor that we have to understand is if you increase fats from the vegetable side of it,
[00:13:39] meaning nuts and avocados and so on, it also tends to make the LDL particles larger. Typically, reduction of the glucose peaks is the key where your LDL is better controlled. They are appropriate in molecular size and more productive. So that's the kind of lifestyle modification I'm talking about. Cut back your carbohydrates, increase the activity immediately after eating.
[00:14:07] And the other one that I will say it, some people like to do this, some people don't like to do this, is apple cider vinegar. And when I first was looking into this, I was thinking how can apple cider, remember I'm a cardiologist and my job is fixing arteries and that's what I normally do. And when I think about apple cider vinegar and so on, I used to think about the saying that is really true. There is data.
[00:14:30] There is data to show that taking one tablespoon of apple cider vinegar, not straight, but mixed with eight ounces of water and drinking that along with food helps to make glucose peaks to be less prominent. And there is a study of that. And if you would like to do that, you're already doing apple cider vinegar may not be a bad thing to do. So continue doing that. That's my point. Yeah, that's interesting. They say apple cider vinegar is one of those things that fixes so many random kind of things,
[00:15:00] but I have heard that that is good for that as well. And speaking about that, with let's say the way that medicine is advancing so quickly now and there's always some kind of new advancements in medicine, but what are some of the newer, more advanced cholesterol tests specifically that people should be aware of? It's not the cholesterol tests like we talked earlier. Advanced lipids that will give us the particles of LDL, particles of HDL, VLDL, which is very low density lipoproteins
[00:15:30] and intermediate density lipoproteins and HDL. So these particles, they give you the particle numbers, they give you the particle size. That helps a lot in determining how to modify your lifestyle medications and diet to move them in the optimal direction. Along with that, I also prefer to check inflammatory markers. One important marker that I tend to check is called Glyca, G-L-Y-C-A,
[00:15:57] that measures glycosylated protein that are an indication of inflammation in the body in the last few months. CRP, which was traditionally used to measure inflammation, was an acute phase kind of a substance that happens when an incident happens with inflammation inside the body, whereas Glyca is a measure of inflammation over the past few months. So I would suggest checking G-L-Y-C-A in Glyca.
[00:16:27] I will also measure, it's called LPPLA-2, gives us the inflammation associated with vascular territory. It's inflammation in the plaque, inflammation in the coronary arteries or anywhere else in the body. That's a good marker of that. These two markers provide us an ability to monitor inflammation inside the body, treat it appropriately or modify your lifestyle appropriately,
[00:16:55] because atherosclerosis in the end is an inflammatory process. And I think if there's one takeaway from today, it's that cholesterol is more than just LDL. And if you're only looking at the basics, you might be missing the bigger picture. And we'll continue breaking down these layers in upcoming episodes from inflammation to imaging to personalized prevention strategies. So if you're ready to take control of your heart health with real clarity, make sure you're following Cardio Now wherever you get your podcasts. And it's always nice to see you, Dr. Mahesh Mulumudi.
[00:17:24] It's always an enlightening conversation. So thank you so much for being here and for having this chat with us. And for everyone listening, we will see you at the next episode. And I can't wait to talk to you soon. Thank you so much.