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The number-one cause of death in women is still heart disease — and perimenopause is where your cardiovascular risk starts to quietly climb. This week, Dr. Komal sits down with Dr. Harpreet Tsui, an internist, obesity medicine specialist, and founder of Coronado Health (a direct primary care practice in Nevada), to break down the 2026 ACC/AHA Dyslipidemia Guidelines — the biggest update to cholesterol guidelines in years.
This is a personal episode. Both physicians are Southeast Asian women with significant family histories of heart disease. Both are managing their own cardiometabolic health in real time. And neither of them is willing to accept "your numbers look fine" as the end of the conversation.
They cover what's changed in the guidelines, which genetic cholesterol markers your doctor may not be ordering, why perimenopause can flip your lipid panel overnight, and the exact language to use at your next appointment to get the full picture.
Guest
Dr. Harpreet Tsui, MD Internist | Obesity Medicine Specialist | Founder, Coronado Health (Direct Primary Care, Henderson, NV)
📍 coronadohealthdpc.com 📱 Instagram & TikTok: @drharpreet.tsui
Timestamps
[0:00] — Podcast intro and medical disclaimer
[1:03] — Meet Dr. Harpreet Tsui: internist, obesity medicine specialist, founder of Coronado Health in Nevada — and why both she and Dr. Komal wanted to have this conversation as Southeast Asian women with significant family histories of heart disease
[2:48] — Why direct primary care: Dr. Tsui on leaving the 15-minute appointment model to build a practice centered on women's health, obesity medicine, and actually having enough time to talk
[4:42] — Guidelines confusion and statins: from the clear LDL targets of residency training to the ambiguous "lower it if you feel like it" era — and why statins have gotten an unfair reputation despite data showing they reduce heart disease, stroke risk, and even drive plaque regression
[7:01] — Mistrust and culture around medications: immigrant family attitudes toward asking for help, the "I can do it on my own" mentality, and how even physicians absorb enough noise to hesitate — including Dr. Tsui, who prescribed herself a statin and left it on her nightstand for two weeks before she could take it
[12:14] — Key update: risk-based treatment replaces number-chasing. The new PREVENT ASCVD calculator factors in HDL, triglycerides, family history, ethnicity, and even zip code — and gives you both a 10-year and 30-year cardiovascular risk estimate, not just a snapshot of today
[16:11] — Perimenopause and lipid shifts: why cholesterol can change dramatically when estrogen drops, even when lifestyle hasn't. Dr. Tsui's LDL went from 77 to 177 in perimenopause. Dr. Komal's Lp(a) was normal before — and then it wasn't. Neither of them did anything differently.
[20:59] — ApoB and Lp(a) explained: the two genetic cholesterol markers now in the 2026 guidelines as independent cardiac risk factors. Your standard lipid panel can look stone-cold normal while these are quietly elevated — and why both physicians now check them routinely on midlife women
[23:28] — Female-specific risk factors are finally in the guidelines: menopause, PCOS, gestational diabetes, and preeclampsia are now formally recognized as independent cardiovascular risk factors. The gestational diabetes gap — including the postpartum glucose tolerance test that routinely gets missed — and why preeclampsia has lifelong cardiovascular implications
[29:32] — Lower LDL targets and the case for being more aggressive: below 70 for high-risk patients, below 55 for very high-risk — and why vascular specialists have been pushing for LDL at or below 50 for years ahead of these guidelines
[31:33] — Beyond statins: PCSK9 inhibitors, ezetimibe, omega-3s, and emerging Lp(a)-targeted therapies in the pipeline — what your options are if you genuinely can't tolerate statins
[32:06] — Why guidelines change — and why that's not the same as being lied to: the science evolves, the tools get better, and the recommendations follow
[33:13] — Pandemic messaging lessons: Dr. Komal on "flatten the curve," what it actually meant, and how the gap between what medicine knows and what gets communicated to the public continues to fuel mistrust
[34:31] — Rebuilding trust in science: Dr. Komal's experience at her Washington hospital during the first COVID deaths in the country, the CDC arriving to learn rather than lead, and why uncertainty in medicine is not the same as deception
[38:33] — Midlife women and heart risk: why cardiometabolic risk isn't discussed nearly enough in the context of menopause, and what Dr. Komal is doing in her own practice to screen every midlife woman proactively — before anything on the standard panel looks alarming
[40:04] — Estrogen loss and metabolic shift: the mechanism behind why visceral fat increases, muscle mass drops, insulin resistance develops, and cholesterol climbs when estrogen declines — and why this is biology, not a lifestyle failure
[41:09] — Inflammation markers and hsCRP: why both physicians check high-sensitivity CRP routinely, what Dr. Komal found when hers came back elevated despite well-controlled autoimmune disease, and the vicious cycle of visceral fat and cardiovascular inflammation
[43:26] — Personal plans, statins, and GLP-1s: Dr. Tsui shares her own treatment journey — transdermal estrogen, a statin, and adding back a GLP-1/GIP combination — and how her LDL dropped back below 70 and her hsCRP normalized. The reminder that everyone's genetics are different, and so is the plan.
[45:22] — Lifestyle first, medication timing: how Dr. Tsui structures the first conversation with patients — a deep dive on diet, body composition, schedule, and food access — and her three-month reassessment framework before deciding on pharmacologic intervention
[47:47] — Calcium scores and hidden disease: the coronary artery calcium (CAC) score as a window into subclinical atherosclerosis — including Dr. Tsui's own score of 214 at age 43, discovered while trying to prove her heart was healthier than her husband's
[50:12] — Statin side effects and PCSK9 inhibitors: managing myopathy, dosing strategies for women (who metabolize statins differently), and how Dr. Tsui gets about 75% of patients who need a PCSK9 inhibitor to actually commit to it
[51:37] — Insurance barriers to care: prior authorization requirements for PCSK9 inhibitors, the specialist referral runaround, and what happens to patients when the system gets in the way of evidence-based treatment
[52:31] — What to ask your doctor: specific language and specific tests — family history, the PREVENT ASCVD calculator, Lp(a), ApoB, fasting insulin, ferritin, GLP-1 conversations, and the "skinny fat" discussion that Southeast Asian patients in particular deserve to have
[55:19] — Family history, kids, and screening: when to start checking cholesterol in children (as early as age two with significant family history), why puberty brings new risk considerations, and a message to primary care physicians and their own patients — including the data on female physician mortality that should make all of us pause
[57:24] — Closing thanks and where to find Dr. Harpreet Tsui: Coronado Health in Henderson, NV | coronadohealthdpc.com | @drharpreet.tsui on Instagram and TikTok
Resources Mentioned
- 2026 ACC/AHA Dyslipidemia Guidelines
- PREVENT ASCVD Risk Calculator (American Heart Association)
- MASALA Trial (South Asian cardiovascular health research)
- Coronado Health: coronadohealthdpc.com
- Clearly Hormonal Episode with Dr. Ambreen Mohamed (CT coronary angiogram and women's heart disease — coming soon)
Connect
Dr. Komal Patil-Sisodia Endocrinologist | Internist | Obesity Medicine | Menopause Society Certified Practitioner 📍 Eastside Menopause & Metabolism — Kirkland, WA | eastsidemm.com 📱 Instagram & TikTok: @drpatilsisodia
Dr. Harpreet Tsui Internist | Obesity Medicine Specialist | Founder, Coronado Health 📍 Henderson, NV | coronadohealthdpc.com 📱 Instagram & TikTok: @drharpreet.tsui
Thanks for listening. Find more info about Clearly Hormonal on the website or Instagram.
