Hey Doc,

Issue 102. I started watching Best Medicine on Netflix yesterday, don't judge please. A heart surgeon leaves Boston for a village practice. He was used to treating the organ, fixing the patient, next. Now he sees his impact on the community he just moved into, good and bad.

What I like about Dr. Best is the relentlessness. The pursuit of the diagnosis, the appetite for investigation, the complete indifference to what anyone thinks of him, and the coldness with which he educates, he could be a bit warmer though. Watch his personality shift across the episodes. I recognized something. I did the same thing for years. Fix the heart, not the health.

That is what this week's cover story is about. Why more doctors are moving into longevity medicine.

And no, this is not an invitation to binge Netflix!

As always, Happy Sunday.
Dr. David Luu, Founder, longevitydocs.™

Each week, I try to explore one idea that could advance longevity medicine and hopefully support physicians in bringing it to life. For my full perspective sign up for my weekly newsletter and follow on substack. Read the full issue on Substack.

Why More Doctors Are Moving Into Longevity Medicine. Part 1/4

Over the next four weeks I am writing one story a week for the physicians thinking about this move. Why doctors are making it. How to actually start a practice. The ecosystem you have to build around it. And what the work looks like in practice. Then on September 13, something opens.

Imagine thirteen minutes to work out what is wrong with your patient, order the tests, interpret them, prescribe, educate, and feel like you practiced medicine. You cannot.

So the visit ends, the patient leaves with the prescription he came in for, and goes looking for the real answer somewhere else. Another doctor, a med spa, a chatbot.

Probably not what you signed up for after ten years of training. You know exactly what I am talking about.

Nearly half our Certified Longevitydocs, across 29 countries, come from primary care, emergency medicine and internal medicine. That surprises people who assume this is a boutique subspecialty for concierge doctors. It is not. The doctors building this field came from the frontline, and they left it wanting better care for their patients.

Ten reasons they give

• 1. Prevent disease instead of managing its complications. Treat the atherosclerosis, not the heart attack.

• 2. Spend time on medicine. Ninety minutes with a patient instead of ninety minutes on prior authorization.

• 3. Get paid for outcomes, not volume. Right now, seeing thirty patients badly pays more than seeing ten well.

• 4. Write protocols for the patient in front of you. Not wait for a committee, not inherit a pathway built for a population that is not yours.

• 5. Follow patients long enough to know the protocol worked. Watch the biomarkers improve instead of referring the patient and never finding out.

• 6. Answer what patients are already asking. When they ask about peptides, be the one who answers instead of the influencer.

• 7. Own the reputation. Patients come to you, not to the logo on the building.

• 8. Own the business. A panel of 150 at $5,000 instead of 2,000 patients you never really see.

• 9. Live what you prescribe. Stop advising people on sleep while running on five hours yourself.

• 10. Freedom. Which is what the other nine add up to.

What nobody tells you

The first year is hard. You are building a business you were never trained to build. Pricing used to be done by the insurer. Now it is yours. So are the protocols, finding your first patients, choosing the technology, hiring the team. Nobody does this alone. That is what opens on September 13.

Next Sunday: Part 2/4 - How to actually start a longevity practice, including what the first year costs and earns. Make sure you're on the list.

A First Look at the longevitydocs Lexicon: the First Physician Research Tool of Its Kind

The longevitydocs Lexicon is a living map of longevity medicine, built on published research and the experience of physicians. This week we explore Lipoprotein(a) in the Lexicon, get access inside longevitydocs.ai. 

Topic: Lipoprotein(a) Also known as Lp(a), Lpa, apo(a)

Definition
Lipoprotein(a) [Lp(a)] is an apoB100-containing lipoprotein whose two major protein components are apoB100 and apolipoprotein(a), and high levels are an independent and causal risk factor for atherosclerotic cardiovascular disease. [1] Lp(a) is predominantly a monogenic (genetically determined) cardiovascular risk determinant, with roughly 70% to 90% of the interindividual variation in levels being genetically determined. [1] High Lp(a) concentrations are present in about 10% to 20% of the population and, on a genetic basis, affect an estimated more than one billion individuals worldwide. [2]

How it works
High Lp(a) drives atherosclerotic cardiovascular disease through mechanisms associated with increased atherogenesis, inflammation, and thrombosis. [1] Epidemiologic and genetic studies involving hundreds of thousands of individuals strongly support a causal and continuous association between Lp(a) concentration and cardiovascular outcomes across different ethnicities, and elevated Lp(a) remains a risk factor even at very low levels of LDL cholesterol. [3] Lp(a) has pro-inflammatory and pro-atherosclerotic properties that may partly relate to the oxidized phospholipids it carries, and high Lp(a) is associated with both microcalcification and macrocalcification of the aortic valve. [3] Effect sizes are most pronounced for myocardial infarction, peripheral arterial disease, and aortic valve stenosis, where high Lp(a) concentrations predict roughly 2- to 3-fold increases in risk. [2]

Connected concepts

How it’s measured
Lp(a) measurement should be performed using well-validated assays with traceability to a recognized calibrator so that common cut-offs for high concentrations and risk assessment can be applied. [2] A recognized limitation is that the field still lacks full standardization and harmonization of assays and universal guidelines for diagnosis and risk assessment. [1] Multiple cardiovascular societies now recommend measuring Lp(a) concentration at least once in all adults, with cascade testing having potential value in familial hypercholesterolaemia or with a family or personal history of very high Lp(a) or premature ASCVD. [3] [4] European consensus recommendations note that Lipoprotein(a) cholesterol is contained within the LDL cholesterol reported on the standard Lipid Panel, and advise estimating it in all patients at risk of atherosclerotic cardiovascular disease [5]

What levels mean / management
In a participant-level meta-analysis of statin-treated individuals, those with an Lp(a) level above 50 mg/dL (about 125 nmol/L) had increased ASCVD risk across all quartiles of achieved LDL-C, confirming Lp(a) as a risk driver independent of LDL-C control. [6] Because no Lp(a)-specific lowering therapy is yet approved for outcome reduction, current guidance is early, intensive management of all other modifiable cardiovascular risk factors in people with elevated Lp(a). [3] Statins do not reduce Lipoprotein(a) and instead tend to increase its levels, an effect proposed to contribute to the residual cardiovascular risk observed in statin outcome trials and clinical practice [7] In primary prevention, elevated Lipoprotein(a) acts as a risk-enhancing factor that refines calculator-based cardiovascular risk estimates, complemented by subclinical atherosclerosis testing with Coronary Artery Calcium scoring to guide preventive therapy decisions [8]

Lp(a) is reported in two NON-interchangeable units: mass concentration (mg/dL, whole-particle protein+lipid) and particle/molar concentration (nmol/L, particle number). There is no universal conversion factor because apolipoprotein(a) isoform size varies between people, so mg/dL and nmol/L do not convert linearly; nmol/L is the preferred molar unit. The paired values shown are the thresholds as reported together in each cited source’s full text, and cut-offs are ancestry-dependent. Assays require traceability to a recognized calibrator (Clin Chem 2021).

Community knowledge
Lipoprotein(a), or Lp(a), is a genetically determined, LDL-like particle with pro-inflammatory and prothrombotic properties that carries substantial atherosclerotic, thrombotic, and aortic-stenosis risk.

Dr. Giovanni Campanile has described Lp(a) as a silent, largely genetically fixed risk factor for which no direct therapy is yet approved, recommending once-in-a-lifetime measurement and cascade testing of first-degree relatives, and noting that high-dose statins can paradoxically raise Lp(a) while PCSK9 inhibitors and apheresis lower it a; he has also emphasized the ApoB/ApoA1 ratio as a highly predictive treatment target d

Dr. Jessica Shepherd, Dr. Saranya Wyles, Dr. Giovanni Campanile, and Dr. Elizabeth Poynor jointly noted that Lp(a) is not perfectly constant and can rise with inflammatory states, remaining a several-fold stronger risk factor than LDL when elevated at any point in life c.

Dr. Simar Randhawa has echoed the guidance to consider trending Lp(a) over time and to lower ApoB and the ApoB/ApoA1 ratio when direct Lp(a) reduction is not yet available b.

The Longevitydocs community have noted that dedicated Lp(a)-lowering agents are anticipated and may become options for high-risk patients.

References

Frequently Asked Questions

How do I sign up for Dr. David Luu’s weekly newsletter?

You can subscribe to Weekly Longevity Medicine Intelligence, Dr. David Luu’s newsletter, at newsletter.longevitydocs.org. It publishes every Sunday for licensed physicians and healthcare professionals, and covers a new cover story, a LongevityDocs Lexicon deep-dive, and a roundup of the week’s longevity medicine news.

Why are doctors leaving traditional practice for longevity medicine?

A reason may be that standard visits do not leave enough time to prevent disease, personalize a protocol, or follow a patient long enough to see it work. Physicians moving into longevity medicine say they get paid for outcomes rather than volume, and they get to practice the medicine they trained for.

What is the LongevityDocs Lexicon?

The longevitydocs. Lexicon is a living map of longevity medicine, built on published research and the experience of physicians who see patients. It is available at longevitydocs.ai for members. Every entry is from a verified physician, a doctor with a license and patients. It was introduced in What People Get Wrong About Longevity Medicine, Issue 101 of the Weekly Longevity Medicine Intelligence newsletter. 

What is Lipoprotein(a) as found in the Longevitydocs Lexicon?

Lipoprotein(a), or Lp(a), is an apoB100-containing lipoprotein that is an independent and causal, largely genetically determined risk factor for atherosclerotic cardiovascular disease, affecting an estimated more than one billion people worldwide on a genetic basis. Dr. Giovanni Campanile, a physician in the longevitydocs network, describes Lp(a) as a silent, largely genetically fixed risk factor for which no direct therapy is yet approved, and recommends once-in-a-lifetime measurement with cascade testing of first-degree relatives.

How is Lp(a) different from LDL cholesterol as found in the Longevitydocs Lexicon?

Lp(a) remains a cardiovascular risk factor even at very low LDL-C levels and is not lowered by statins, which can paradoxically raise it. Dr. Jessica Shepherd, Dr. Saranya Wyles, Dr. Giovanni Campanile, and Dr. Elizabeth Poynor, physicians in the longevitydocs network, have jointly noted that Lp(a) is not perfectly constant and can rise with inflammatory states, remaining a several-fold stronger risk factor than LDL when elevated at any point in life. Dr. Simar Randhawa recommends trending Lp(a) over time and lowering ApoB and the ApoB/ApoA1 ratio when direct Lp(a) reduction is not yet available.

What is longevitydocs?

longevitydocs.™ is the world’s leading vetted physician network, offering physician-only access to evidence, peers, events, and true infrastructure for growth. Also home to the Certified longevitydocs (CLD) longevity medicine certification, built by physicians for physicians. The community is designed for those committed to advancing evidence-based longevity care and uniting the best specialties across functional medicine, cardiology, hormone health, and regenerative medicine.

Do I need to already BE practicing longevity medicine to be part of the longevitydocs community?

No. Longevitydocs member community spans 1,200+ doctors across 68+ countries from all different areas of expertise. Nearly half of all Certified Longevitydocs alumni, across 29+ countries come from primary care, emergency medicine, and internal medicine... not everyone here is from concierge or boutique backgrounds.

I’m exploring longevity medicine certification. What is the Certified Longevitydocs CLD?

The Certified longevitydocs™ (CLD) is the world’s first longevity medicine certification for physicians: 100+ hours of curriculum across 10 modules, from Biology of Aging and Testing and Diagnostics to Specialty Integrations and Practice Leadership, self-paced over 6 to 9 months alongside a full clinical schedule. Graduates earn the Certified Longevitydocs™ credential and join a working network of 1,200+ physicians across 68+ countries.

How is the longevitydocs CLD different from traditional programs?

Traditional certification programs stop at the curriculum. The Certified longevitydocs™ (CLD) is built as infrastructure: 100+ hours across 10 modules taught by faculty from Harvard, Stanford, Mayo Clinic, and the Buck Institute, plus downloadable protocols and assessment tools built for the exam room. What no traditional program offers is what comes after the coursework: direct access to the longevitydocs.ai platform, Hippo, an AI learning assistant trained on the CLD curriculum, live Rooms where physicians workshop real cases and business decisions together, and a working network of 1,200+ longevity physicians across 68+ countries solving the same clinical and business problems in real time. It’s self-paced over 6 to 9 months alongside a full clinical schedule. Read four physicians’ real ROI stories in How Longevity Medicine Certification Propels Your Practice: The ROI.