What if the sequence we've always assumed—plaque causes arterial stiffness—is actually backwards? Dr. Lily Johnston proposes that impaired nitric oxide signaling may stiffen arteries first, creating the endothelial injury that then promotes plaque formation.

Dr. Lily Johnston is a board-certified vascular surgeon and newly certified obesity medicine physician who bridges the operating room and metabolic medicine. After years of scraping plaque from arterial walls, she began questioning why surgical outcomes remain so modest—and discovered that what she was treating might represent the end stage of multiple distinct disease phenotypes, not a single condition.

In this episode, Dr. Johnston shares her forest fire analogy for understanding LDL risk, explains why tissue surrounding diseased arteries shows profound inflammation even in first-time surgeries, and reveals why 80–90% of the operations she performs could potentially be prevented with upstream metabolic intervention.

Questions Answered in This Episode:

• Do metabolically healthy people with elevated LDL need the same treatment as those with active disease?
• Why might someone with "great" biomarkers still have significant plaque burden?
• What will individualized cardiovascular treatment look like in 20 years?
• To what extent is vascular disease a metabolic disease—and is this accepted in vascular surgery?
• Where do you stand on the LDL particle number vs. metabolic context debate?
• What percentage of vascular surgeries could have been avoided with earlier metabolic intervention?

A surgeon's-eye view of what happens when metabolic dysfunction goes unaddressed for decades—and a practical framework for intervening before the fire starts.

Find more of Dr. Johnston online:

• Live Q&A
• Youtube channel
• LinkedIn
• Coresight Health

Special thanks to the sponsors of this episode:

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Please keep in mind: The Metabolic Link does not provide medical or health advice, but rather general information that does not serve as a substitute for a licensed healthcare professional. Never delay in seeking medical advice from an appropriately licensed medical provider for any health condition that you may have.