The Healthy Guy Who Almost Died
I was eight. Maybe nine. Third or fourth grade.
I woke up in a house that wasn’t mine. A doctor I’d never seen stood in the hallway. Red overalls. Paramedics moved quickly, silent. My mother was there, holding it all together because no one else would.
My father was only 38, and he was the strongest person I knew. But that morning, he was having a heart attack.
He survived, but he was different after that. I’ll return to this later.
Like most kids, I tried to hide that fear. I put that morning out of my mind and let life move on: school, wrestling, exams, med school, my first job, my own children, my career.
Then you hear about people like Bob Harper or Jim Fixx, and suddenly those memories and feelings come back.
Bob Harper, nine minutes dead
February 12, 2017. A gym in Manhattan. Bob Harper was 51, finishing a workout [1]. If you watched TV between 2004 and 2016, you know him from The Biggest Loser. He was the loud coach who built his career on the idea that you can outwork any body.
He collapsed on the gym floor. No pulse for what he has said was nine minutes. [2].
The only reason he’s alive today is that a cardiologist happened to be there and started CPR while someone else called an ambulance [2]. Being without a pulse for nine minutes is extremely rare to survive. Most people don’t come back from that.
The blocked artery was the left anterior descending. Cardiologists call it the widowmaker, and the name fits.
In the workup after he survived, they found the root cause. An inherited genetic condition. High lipoprotein(a). One of the strongest hereditary risk factors for a heart attack we know about [1]. It had been sitting in his bloodstream since the day he was born. He’d had a cholesterol test every year of his adult life. Nobody had ever ordered the one that would have found it.
This newsletter is about the difference between looking healthy and actually being healthy. Five numbers can close that gap. Most aren’t included in your yearly checkup. All of them would have warned Bob Harper, at 40, that he was at serious risk.
They would have warned my father too.
Training didn’t erase the disease
This information isn’t new.
Masters endurance athletes over 40, with otherwise clean cardiovascular risk profiles, have been imaged and re-imaged in study after study. Nearly half have visible coronary plaque [4]. The MASTER@HEART trial ran the proper comparison in 2023 and confirmed the pattern: lifelong endurance athletes carry more atherosclerosis than healthy non-athletes, not less [5]. Their plaque skews toward the calcified, more stable form, and whether that translates to worse outcomes is still debated. But the simple protective narrative sold by the running industry is not supported.
When men over 40 drop dead during a marathon, the autopsy most often shows the same cause. Coronary artery disease. Plaque that’s been building for 20 years while the runner logged his miles, ate his salads, and told himself the training was protecting him [6].
Training helped, but it couldn’t get rid of the disease.
This isn’t a modern problem. In July 1984, a man called Jim Fixx collapsed on a run in Vermont. He was 52. He wrote The Complete Book of Running. Sold around 4 million copies. Helped launch the jogging boom in America [7]. The autopsy was clean. One coronary artery 95% blocked. A second 85%. A third 70% [7]. His father had died of a heart attack at 43.
42 years later, we have better tests, better treatments, and enough evidence to spot this pattern ten years before it becomes deadly. But almost nobody is getting these tests.
Your yearly checkup was designed to find disease, not prevent it. The lipid panel you get was created in the 1970s [8]. ApoB has been a better predictor of heart risk for 20 years [9], but most primary care doctors still don’t order it. It’s not out of malice, just habit.
It’s this habit, more than any lab result, that leads to so many health problems for executives.
Five numbers. Remember them.
I’m a doctor and health nerd, and I read this research for fun. Here are the five numbers I want you to remember.
ApoB. Your LDL result tells you how much cholesterol is floating inside your lipoprotein particles. ApoB tells you how many particles there are. Plaque is driven by the number of atherogenic particles depositing in artery walls, not just the cholesterol they carry. Count the particles, not the passenger. When the two numbers disagree, ApoB is the one telling the truth.
The most rigorous analysis we have covers 15 studies and close to 600,000 people. In every single head-to-head comparison, ApoB beat LDL as a predictor of heart attack and stroke [9].
Your LDL might look normal while your ApoB is high. This happens most often in people with some belly fat, rising triglycerides, or insulin that’s not working right. Honestly, that’s most people reading this. Some of you might even be in a weekly strategy meeting, thinking you’re fine because your Peloton stats look good.
Target: ApoB under 80 mg/dL. Under 65 if you already have disease or a strong family history.
Lipoprotein(a), or Lp(a). This is the number Bob Harper had never been tested for.
It’s genetic. You’re born with it, and that’s it. No lifestyle intervention moves it, and currently available drug therapies only offer modest reductions. Statins don’t lower it, and some research suggests statins might even raise it a bit [10]. The first effective, dedicated Lp(a)-lowering therapies are the RNA-based agents in late-stage trials.
1 in 5 adults carries elevated Lp(a). Around 64 million people in the US alone [10]. At high levels, it multiplies your cardiovascular risk by 2 to 4x on top of everything else you’ve got going on. Threshold: 50 mg/dL, or 125 nmol/L. Above 180 mg/dL is the extreme-risk zone. You measure it once in your life.
A treatment is coming. A Phase 2 trial published in 2025 showed that one injection of lepodisiran lowered Lp(a) by up to 94%, and the effect lasted almost a year [11]. Phase 3 trials are underway. Approval is expected in the next few years, but you shouldn’t wait to get screened.
If the level is high, drive ApoB low, treat blood pressure aggressively, avoid smoking, consider a PCSK9 inhibitor in high-risk cases, and await new therapies. As always, talk to your doctor about your specific case.
HOMA-IR. A simple calculation from your fasting insulin and fasting glucose.
Insulin resistance appears a decade before type 2 diabetes, and about the same amount of time before heart disease [12]. Your yearly checkup measures fasting glucose, but glucose is the last thing to change. By the time it’s abnormal, the disease has been developing quietly for years.
Fasting insulin changes first. A HOMA-IR above 2 to 2.5, depending on which cutoff your lab uses, indicates insulin resistance [12]. This is behind many of the health problems that affect executives before age 70.
hs-CRP. Inflammation is what turns stable plaque into a heart attack. The plaque itself isn’t deadly, but when it ruptures, it is.
A major 2023 analysis of more than 31,000 statin-treated patients found that hs-CRP predicted the next heart attack, stroke, and cardiovascular death more strongly than LDL cholesterol did [13]. The inflammation number beat the cholesterol number.
In a dedicated trial, an anti-inflammatory drug that didn’t lower LDL still reduced heart events by 15% [15]. The 2025 ACC scientific statement now treats inflammation as a direct target for treatment [14]. The goal is to keep it under 2 mg/L. If it’s higher, even with perfect LDL, you still have real risk.
The coronary artery calcium (CAC) scan. The other four tests show causes. This one shows the result, made visible.
A 30-second low-dose CT scan of your chest. It returns a single number that measures how much calcified plaque is already in your coronary arteries. Each doubling of the CAC score is associated with a roughly 25% increase in near-term event risk [16]. A score of zero buys you a multi-year warranty period of low near-term risk [17]. However, a zero CAC is a strong reassurance but not absolute, especially in younger people or those with high Lp(a), where soft plaque can still be present. A score above 100 for someone under 55 means advanced disease for age, right now. In older adults, the threshold shifts.
It’s arguably the most useful single preventive test for asymptomatic adults. Most people you know have never had one. Disclaimer: The radiation dose is roughly 1 mSv, low, but non-zero.
That’s just the truth.
Fitness helps protect you, but it doesn’t erase the risk.
You can’t exercise away an ApoB of 130. You can’t meditate away an Lp(a) of 200. You can’t fix a HOMA-IR of 4 with cold plunges.
The men and women who die running marathons in their late 40s weren’t out of shape. They just weren’t screened.
The wellness industry has taught you to focus on the wrong things. You track your sleep, monitor your HRV, count your steps, and drink turmeric. But the real numbers that show if your arteries are closing have never been checked.
Check the foundation before you start fixing the roof.
I mean this seriously.
Where this fits in the Upward ARC
Regular readers know the three pillars. Activate. Recover. Capacity.
These five numbers sit upstream of all three.
You can’t Activate with any precision if you don’t know whether you’re carrying a decade of silent disease. You can’t Recover from a process you haven’t measured. You can’t build Capacity on a foundation that’s been quietly cracking for 20 years.
One appointment and five tests can make everything you do next much clearer.
Try this today
Schedule your bloodwork this week. Ask your doctor for four tests: ApoB, Lp(a), fasting insulin (with fasting glucose), and hs-CRP. But, the pattern compounds with age. If you’re under 35 with no family history, ApoB and Lp(a) alone are high-yield. The full panel becomes clearly indicated from the late 30s onwards.
If your doctor resists or doesn’t know these tests, find another one who is up to date. Most big cities have private screening clinics, preventive cardiology practices, and doctors focused on longevity. They’re out there and run these tests every day. You can find them if you look.
Schedule a coronary artery calcium scan before you turn 45. If you’re over 45 and haven’t had one, do it as soon as you can. The scan takes 30 seconds. If your first score isn’t zero, repeat it every 3 to 5 years. That one number will guide your medical decisions for the next decade more than anything else.
Measure your waist at your belly button and divide by your height. If the result is over 0.5, you have visceral fat, no matter what the scale or mirror says [18]. All you need is a tape measure and two minutes. Being thin on the outside doesn’t mean you’re thin on the inside.
Change the conversation with your doctor when you bring in your results. Don’t just ask if your LDL is fine. Instead, ask: What is my ApoB? What is my Lp(a)? What is my CAC? What can I do to lower my real risk?
Asking a new question can shape the next ten years of your life.
And while you’re at it: if you smoke, stop. If your resting blood pressure is above 130/80, get it under. Those two sit alongside the five numbers, not underneath them.
Back to my father
My father survived. He did the rehab, took his medications, and did everything right. But he never fully recovered.
The man who left the hospital wasn’t the same as the one who went in. His energy, strength, drive, and even his patience for daily life were all a little less. That change was permanent.
He retired early. In our family, we always knew that choice went back to that morning when I was eight. It wasn’t just the heart attack, but what it took from him.
We often talk about heart attacks as if it’s just about surviving or not. But the real story is quieter and lasts much longer. You don’t get the same body back. You get what doctors and your own body can rebuild, minus what the heart attack took away.
Get these numbers checked while you still can.
This body is the only one you have.
Stay healthy.
Andre
References
Harper, B. (2017–2024). Public statements on the February 2017 cardiac arrest, recovery, and lipoprotein(a) diagnosis. Today Show; CNN Health; AARP The Magazine; Family Heart Foundation speaking engagements.
Marquez, M. (2017, February 17). Bob Harper opens up about his “widowmaker” heart attack. CNN Health. https://www.cnn.com/2017/02/17/health/bob-harper-biggest-loser-heart-attack/index.html
Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., Avery, C. L., et al. (2023). Heart Disease and Stroke Statistics: 2023 Update. A Report From the American Heart Association. Circulation, 147(8), e93–e621. https://doi.org/10.1161/CIR.0000000000001123
Merghani, A., Maestrini, V., Rosmini, S., Cox, A. T., Dhutia, H., Bastiaenan, R., et al. (2017). Prevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profile. Circulation, 136(2), 126–137. https://doi.org/10.1161/CIRCULATIONAHA.116.026964
Aengevaeren, V. L., Mosterd, A., Sharma, S., Prakken, N. H. J., Möhlenkamp, S., Thompson, P. D., et al. (2023). Exercise volume versus intensity and the progression of coronary atherosclerosis in middle-aged and older athletes: findings from the MASTER@HEART study. European Heart Journal, 44(48), 5092–5102. https://doi.org/10.1093/eurheartj/ehad571
Kim, J. H., Malhotra, R., Chiampas, G., d’Hemecourt, P., Troyanos, C., Cianca, J., et al. (2012). Cardiac arrest during long-distance running races. New England Journal of Medicine, 366(2), 130–140. https://doi.org/10.1056/NEJMoa1106468
Altman, L. K. (1984, July 22). James F. Fixx dies jogging; author on running was 52. The New York Times. https://www.nytimes.com/1984/07/22/obituaries/james-f-fixx-dies-jogging-author-on-running-was-52.html
Friedewald, W. T., Levy, R. I., & Fredrickson, D. S. (1972). Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clinical Chemistry, 18(6), 499–502.
Sniderman, A. D., Thanassoulis, G., Glavinovic, T., Navar, A. M., Pencina, M., Catapano, A., & Ference, B. A. (2025). Apolipoprotein B versus low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol as the marker of atherogenic risk: a systematic review. Journal of Clinical Lipidology. Advance online publication.
Reyes-Soffer, G., Ginsberg, H. N., Berglund, L., Duell, P. B., Heffron, S. P., Kamstrup, P. R., et al. (2022). Lipoprotein(a): a genetically determined, causal, and prevalent risk factor for atherosclerotic cardiovascular disease. A scientific statement from the American Heart Association. Arteriosclerosis, Thrombosis, and Vascular Biology, 42(1), e48–e60. https://doi.org/10.1161/ATV.0000000000000147
Nissen, S. E., Wang, Q., Nicholls, S. J., Navar, A. M., Ray, K. K., Schwartz, G. G., et al. (2025). Lepodisiran, a long-duration small interfering RNA targeting lipoprotein(a): a Phase 2 randomized clinical trial (ALPACA). New England Journal of Medicine. Advance online publication.
Tabák, A. G., Jokela, M., Akbaraly, T. N., Brunner, E. J., Kivimäki, M., & Witte, D. R. (2009). Trajectories of glycaemia, insulin sensitivity, and insulin secretion before diagnosis of type 2 diabetes: an analysis from the Whitehall II study. Lancet, 373(9682), 2215–2221. https://doi.org/10.1016/S0140-6736(09)60619-X
Ridker, P. M., Bhatt, D. L., Pradhan, A. D., Glynn, R. J., MacFadyen, J. G., & Nissen, S. E., for the PROMINENT, REDUCE-IT, and STRENGTH Investigators. (2023). Inflammation and cholesterol as predictors of cardiovascular events among patients receiving statin therapy: a collaborative analysis of three randomised trials. Lancet, 401(10384), 1293–1301. https://doi.org/10.1016/S0140-6736(23)00215-5
American College of Cardiology. (2025). 2025 ACC scientific statement on inflammation in atherosclerotic cardiovascular disease. Journal of the American College of Cardiology. Advance online publication.
Ridker, P. M., Everett, B. M., Thuren, T., MacFadyen, J. G., Chang, W. H., Ballantyne, C., et al., for the CANTOS Trial Group. (2017). Antiinflammatory therapy with canakinumab for atherosclerotic disease. New England Journal of Medicine, 377(12), 1119–1131. https://doi.org/10.1056/NEJMoa1707914
Detrano, R., Guerci, A. D., Carr, J. J., Bild, D. E., Burke, G., Folsom, A. R., et al. (2008). Coronary calcium as a predictor of coronary events in four racial or ethnic groups. New England Journal of Medicine, 358(13), 1336–1345. https://doi.org/10.1056/NEJMoa072100
Blaha, M. J., Cainzos-Achirica, M., Greenland, P., McEvoy, J. W., Blankstein, R., Budoff, M. J., et al. (2016). Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation, 133(9), 849–858. https://doi.org/10.1161/CIRCULATIONAHA.115.018524
Ashwell, M., Gunn, P., & Gibson, S. (2012). Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis. Obesity Reviews, 13(3), 275–286. https://doi.org/10.1111/j.1467-789X.2011.00952.x
A note for new readers:
I’m a trained reconstructive facial surgeon, medical doctor, and dentist. Before launching this newsletter, I had a varied career: competitive freestyle wrestler, management consultant (McKinsey), entrepreneur (Zocdoc, Thermondo, and docdre ventures), and corporate executive (Sandoz). Today, I’m a Managing Director and Partner at BCG.
Husband of one. Father of three. Split between Berlin’s urban pulse and our Baltic Sea retreat. I’d rather be moving than sitting. Not just hobbies. Research. My body is my primary laboratory; I’ve been conducting experiments for decades.
If this is your first time here, welcome. I’m excited to share what I’ve learned and will continue to learn with you.
DISCLAIMER:
Let’s get one thing straight: None of this, whether text, graphics, images, or anything else, is medical or health advice. This newsletter is here to inform, educate, and (hopefully) entertain you, not to diagnose or treat you.
Yes, I’m a trained medical doctor and dentist. No, I’m not your doctor. The content here isn’t a replacement for professional medical advice, diagnosis, or treatment.
If you have questions about your health, talk to your physician or a qualified health professional. Don’t ignore their advice or delay getting care because of something you read in The Upward ARC. Be smart. Do your research. And, as always, take care of yourself.