So.

It's gonna be really interesting, and these are gonna be important questions because how many patients d- uh, exist in this world who have had an event and have high Lp(a) and are wondering, "What do I do with this information? How do I make sense of it?" I have conversations with other doctors all the time about, "What do you do with this value for this patient? They've had an MI.

Their LDL seems like it's well-controlled.

Do I do anything else? Is my-- Should my LDL goal be 40? Should it be 55? Should I treat a little bit more aggressively with blood pressure?" You know, the high-sensitivity CRP being so low in this group says to me there's probably a lot less insulin resistance visceral fat than in a lot of the cohorts that I treat because so much of that in the real world, those mildly elevated high-sensitivity CRPs are just driven by the low-grade inflammation associated with visceral fat and obesity.

I'm really looking forward to having more information.

And the other sort of one hypothesis that we haven't touched on that I think needs to be brought up is, are we sure pelacarsen didn't have any non-Lp(a)-related cardiovascular impact? The answer is probably not because all of the preliminary data from phase one, phase two didn't suggest it.

But the history of medicine is sort of littered with things that seemed like they should have worked and then didn't work when they were ultimately tested.

What are the other things right now that are popping up in your world where you think, "Oh yeah, this is something that we should be talking about and that we should be discussing"?

How might you actually talk through a sequence of treatment for them?

Yeah.

So a coronary artery calcium score, or a CAC score, is a ver- It's a very controversial area in medicine, and I think a lot of cardiologists have been very eager to sort of, like, jump on the bandwagon of get a lot of imaging, and there have been a lot of smart people who look at that as the cardiologists are insane because the RCT data just, like, is not there to support that as an intervention.

And I understand that perspective, but I kind of disagree with that perspective.

And so, you know, the, a c- a CAC score, there's two different types of imaging of the coronary arteries that we can do with a CT scan.

The first and most basic is a coronary calcium score, or a CAC score.

That is a low-radiation, zero-contrast chest CT that basically looks to see is there any calcium buildup in the arteries around the heart.

So considering that there may be some underlying insulin resistance present, even with his, quote, "normal A1c," for a motivated patient like Gary, is there any value to checking like a, a fasting insulin or a HOMA-IR, or can you just use the, the triglyceride to HDL ratio to spot the danger?

How might you actually talk through a sequence of treatment for them? Yeah.

So a coronary artery calcium score or a CAC score is a very it's a very controversial area in medicine.

And I think a lot of cardiologists have been very eager to sort of like jump on the bandwagon of get a lot of imaging.

And there've been a lot of smart people who look at that as the cardiologists are insane because the RCT data just like is not there to support that as an intervention.

And I understand that perspective, but I kind of disagree with that perspective.

And so, you know, a CAC score, there's two different, types of imaging of the coronary arteries that we can do with ct skin the first and most basic is a coronary calcium score or a cac score that is a low radiation zero contrast chest ct that basically looks to see is there any calcium buildup in the arteries around the heart and i always tell patients probably heard the term hardening of the arteries before.

Well, a calcium score is looking to see if you have any signs of hardening of the arteries.

So considering that there may be some underlying insulin resistance present even with his, quote, normal A1c, For a motivated patient like Gary, is there any value to checking like a fasting insulin or a HOMA-IR, or can you just use the triglyceride to HDL ratio to spot the danger?