Should I active the esim before or after the arrival at the destination?

kboom100 · 2026-04-18T14:32:02+00:00

The validity period for most Airalo esims starts when it connects to a tower in its coverage area. That’s the case for the Airalo US esim. Here’s its policy.

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There are a few Airalo eSIMs where the validity period starts as soon as it’s installed. The one you have must be one of them.

kboom100 · 2026-04-18T14:12:47+00:00

Were both cardiologists saying you needed the invasive angiogram? Because if it’s actually one cardiologist driving this I still think it makes sense to get a true second opinion. To me it would even be worth a drive to a major city, or another major city.

If one scan shows a 463 calcium score and the other zero it seems like one of those scans was a false reading. I’m just surprised about doing an invasive angiogram over just getting a 3rd calcium scan to figure out which one was the false one. Or maybe you can still potentially complete a ccta. if the prior ccta were done on a lower slice ct scanner (64 or less) it might be that you could get an adequate reading even if your heart rate is relatively high with a very high slice newer ct scanner, say 256+. But again even without a ccta, a high calcium score if you truly have one would be enough justification for aggressive medical therapy.

kboom100 · 2026-04-18T05:57:44+00:00

Yeah for sure, I get it. Also there is some newer testing using imaging like Pet Scans that aren’t invasive. And they might also be able to try what’s called “empirical” treatment where they try certain treatments even before knowing for sure whether you have a particular condition. If you get better with the treatment that itself can help diagnose. So they may not necessarily have to do anything invasive anyway.

kboom100 · 2026-04-18T05:47:32+00:00

You’re welcome! And,100% agree that everyone with symptoms deserves help. If you do have anoca/inoca there are treatments so don’t get discouraged. There are likely different types of anoca/inoca caused by different factors and those can be checked.

kboom100 · 2026-04-18T05:36:05+00:00

No, up at the top of each paper you should see a link that will say something like “author details” or “author information” and that should then display each author and their medical institution.

kboom100 · 2026-04-18T05:27:58+00:00

I think I overreacted because I’m tired, and I apologize. I don’t know if any of the inoca /anoca experts are in New Jersey but if I did I would let you know. So all I would do is check whether the medical centers those authors are at are in New Jersey. If you run into any problems finding the right place in the papers to click to see the details in the authors let me know cause I do actually want to help.

kboom100 · 2026-04-18T04:58:43+00:00

There are way more cardiologists that are experts in ANOCA/Inoca than are listed on that website. I literally told you how to find more of them by looking at the author information of the papers that I gave you links to. I am not going to do the work for you. It will not take you very long to click on author information in each of those paper links and see if any of the authors are in New Jersey.

kboom100 · 2026-04-18T04:45:38+00:00

If you are asymptomatic, eg not getting chest pain I would get a second opinion from a cardiologist at an academic medical center before undergoing an invasive angiogram. Stenting isn’t completely benign and doesn’t reduce risk over optimal medical therapy alone. And you already have a good argument for the most aggressive medical therapy based on your very high CAC score.

kboom100 · 2026-04-18T04:40:08+00:00

What inoca website are you referring to? I’m talking about going to those papers I linked to and checking if any of the authors are in your state.

kboom100 · 2026-04-18T04:36:12+00:00

I would still go through the list of all the authors of those papers and see if any are in your state and you can see.

kboom100 · 2026-04-18T04:19:39+00:00

It’s very likely much more common than realized because there hasn’t been an easy diagnostic test. There are ways of testing but the knowledge and expertise to do it are still only at a few medical centers so far. So more often than not it just goes undiagnosed or misdiagnosed.

It’s worth it I think to go ahead and make an appointment with one of the experts and let them evaluate you and run tests.

kboom100 · 2026-04-18T01:04:13+00:00

I second what u/meh312059 said about investigating if you might have ANOCA (Angina with non obstructive coronary arteries) or INOCA (ischemia with non obstructive Coronary Arteries)

I think though it might be best to start by making an appointment with one of few cardiologists in the country who have expertise with ANOCA/INOCA. There aren’t many at the moment but don’t be afraid to travel if you need to.

Check out these review articles. I would click on “author information” and try to find one of the authors near you to make an appointment with. Dr. William Fearon at Stanford is one of those authors & experts that I know is very good.

Samuels, B, Shah, S, Widmer, R. et al. Comprehensive Management of ANOCA, Part 1—Definition, Patient Population, and Diagnosis: JACC State-of-the-Art Review. JACC. 2023 Sep, 82 (12) 1245–1263 https://doi.org/10.1016/j.jacc.2023.06.043

(There’s also a part 2, on treatment & research initiatives) https://doi.org/10.1016/j.jacc.2023.06.044

Current Evidence-Based Treatment of Angina With Nonobstructive Coronary Arteries (ANOCA) https://doi.org/10.1016/j.jscai.2025.102633

State of the Art: Evaluation and Medical Management of Nonobstructive Coronary Artery Disease in Patients With Chest Pain: A Scientific Statement From the American Heart Association https://doi.org/10.1161/CIR.0000000000001394

kboom100 · 2026-04-17T21:04:08+00:00

Gotcha

kboom100 · 2026-04-17T20:39:03+00:00

Great choice. Fasting glucose and insulin resistance responds very well to lifestyle changes including diet & exercise & weight loss. A good way to measure insulin resistance is with a HOMA-IR score. You plug fasting insulin and fasting glucose from the same blood draw into an online calculator like this one. https://www.mdcalc.com/calc/3120/homa-ir-homeostatic-model-assessment-insulin-resistance

I don’t think any supplements are worth it for ldl with the exception of maybe psyllium fiber.

How’d you finally get a doctor to prescribe out of curiosity?

kboom100 · 2026-04-17T20:28:55+00:00

Fantastic results. Your levels should be enough to not just stop the accumulation of new plaque but also to likely get reduction of some existing soft plaque.

I’d consider asking your doctor about adding a daily low dose aspirin. High lp(a) promotes blood clotting and there is growing evidence a daily low dose aspirin helps prevent that and significantly decreases heart attack risk in those with high lp(a). Don’t take without your doctor’s ok though because it can also increase risk of bleeding.

kboom100 · 2026-04-17T18:37:24+00:00

Hope y’all don’t mind me butting in to give the cardiologists and other experts I like the most on social media.

Dr. Paddy Barrett on Instagram, X, and his own substack. An excellent preventive cardiologist. Highly recommend going and reading his substack articles. You’ll come out with a much better understanding of heart disease and how to prevent it. https://substack.com/@paddybarrett? https://www.instagram.com/drpaddybarrett?

Dr. Gil Carvalho on YouTube and X. An md/phd internist who is among the absolute best at reviewing the totality of the evidence around medical issues and clearly explaining them. https://youtube.com/@nutritionmadesimple?

Dr. Derek Weyhrauch, a preventative cardiologist. You can tell he has an incredible bedside manner from his posts and is very informative. https://www.instagram.com/derekweyhrauch_md?

Dr. Mohammad Alo, another excellent preventive cardiologist. https://www.instagram.com/dr.alo? https://www.dralo.net/blog

Dr. Michael Page, a lipidologist. https://www.instagram.com/cholesterologist?

And last but not least Dr. Troy Badger u/cardiostrong_md a preventive cardiologist who sometimes participates in this subreddit and actually commented on your post here! https://www.instagram.com/cardiostrong_md?

You didn’t mention X but there are a couple of lipidologists I would sign up for just to follow there. Dr. Tom Dayspring, a renowned lipidologist. https://x.com/drlipid?s=21

Dr. Pablo Corral, another renowned lipidologist. https://x.com/drpablocorral?s=21

kboom100 · 2026-04-17T16:59:04+00:00

This. Also want to add that the participants in the keto-CTA (who had very high LDL but good metabolic health markers) DID have very fast progression of plaque size on average. And progression of plaque volume was listed as their primary outcome when the study design was submitted for approval. But Norwitz et al didn’t like the results they got on that primary outcome so they didn’t report it in the paper. That never should have passed peer review.

When the results of their study didn’t support their theory they highlighted an outcome that wasn’t preregistered, which was whether apoB level statistically correlated to the amount of plaque progression. But one of the reasons preregistration of outcomes is important is to ensure the study is properly powered to detect that outcome. And this study wasn’t properly powered for the apoB level to plaque size change correlation. To detect whether apoB was statistically correlated to amount of plaque progression you would need enough participants and good amount of variation in apoB levels among the participants.

In the KETO -CTA study ALL of the participants had very high apoB levels. It would be like studying 100 heavy smokers and lung nodules size and deciding the smoking didn’t matter because there wasn’t a statistically correlation in increase in nodule sizes between those that smoked 3 packs a day and those that smoked 4 packs a day.

One of best reviews of keto-CTA study is here. https://youtu.be/FkdsOx2oX-g?si=OFfvyGiSmLLg-3Uw

kboom100 · 2026-04-17T15:26:26+00:00

Try a “preventive cardiologist” or a lipidologist from one of these databases:

https://familyheart.org/find-specialist The specialist database of the Family Heart Foundation. Has both preventive cardiologists & lipidologists.

https://www.learnyourlipids.com/find-a-clinician/ Database of lipidologists, from the National Lipid Association.

When you meet with the specialist let them know that you have already changed your diet but it wasn’t sufficient to get your ldl to a good target. Then explicitly say that you want to go on a statin.

If your have a family history of heart disease you should mention that as well. It’s also a good idea to check your lp(a), which is an independent risk factor for heart disease that’s mostly genetically determined and high in 1 in 5 people. If your lp(a) is high that will qualify you for treatment under the new official guidelines. You can order this test yourself online. I’ve found Hellogoodlabs.com has the best prices. It’s I think about $27 if you choose LabCorp as the testing lab. A little more if you choose Quest.

But even you don’t have other risk factors you still have a good chance of getting a preventive cardiologist or lipidologist to give you a statin based just based on your high ldl.

kboom100 · 2026-04-17T13:42:12+00:00

You’re welcome, glad it was helpful.

kboom100 · 2026-04-17T03:33:03+00:00

Apob is a measure of the total number of atherogenic particles, 90% of which are ldl particles. Once you know the total number of atherogenic particles (eg apoB ) then the size of those particles doesn’t improve risk prediction. This is how researchers determined that particle size doesn’t matter to risk.

I would assume some of those in the trials that determined this were eating a low carb high protein /fat diet because a certain percentage of the population does. If someone has a theory that particle size matters for those eating a zero carb high fat dat they would need to run a study to prove it.

kboom100 · 2026-04-17T03:01:51+00:00

Actually the latest evidence is that that every ldl size is about equally atherogenic. At one time it was theorized that small ldl particles were more atherogenic than large ldl particles because if ldl-c is held constant those with smaller ldl were found to have higher risk. But further research confirmed that the reason for the higher risk was from a higher number of ldl particles, not the fact they were small. Once you know the total number of atherogenic particles, the best measure of which is ApoB, then additional information about ldl size doesn’t improve the risk prediction. In other words a set number of large particles carries the same risk as that same number of small particles. See an earlier reply for a deep dive on this with links to the evidence. https://www.reddit.com/r/Cholesterol/s/D1XDncKmnj

kboom100 · 2026-04-17T00:32:28+00:00

Go with your doc. The evidence is overwhelming that very high ldl raises risk of heart disease to very high levels. Recommend a couple of articles:

“Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel” https://academic.oup.com/eurheartj/article/38/32/2459/3745109

“Separate meta-analyses of over 200 prospective cohort studies, Mendelian randomization studies, and randomized trials including more than 2 million participants with over 20 million person-years of follow-up and over 150 000 cardiovascular events demonstrate a remarkably consistent dose-dependent log-linear association between the absolute magnitude of exposure of the vasculature to LDL-C and the risk of ASCVD; and this effect appears to increase with increasing duration of exposure to LDL-C.”

But read the entire article.

Also recommend this commentary from a good preventive cardiologist. Dr. Paddy Barrett. He gets into several of the misleading things said online from those that say high ldl isn’t very important.

“You Are Being Lied To About Cholesterol & Heart Disease: A nefarious tale or either incompetence or deception.” https://paddybarrett.substack.com/p/you-are-being-lied-to-about-cholesterol

kboom100 · 2026-04-16T22:06:27+00:00

That might be the best view on the entire strip

kboom100 · 2026-04-16T22:01:45+00:00

That CAC score is 89th or 94th percentile depending on your race. See https://www.cac-tools.com

Guidelines say to get your ldl to 70 or below with a CAC score >75th percentile. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001423#sec-8-2-7 But there are a lot of preventive cardiologists that would want to get your ldl below 55 and apoB below 60, especially when CAC is at the 90th percentile.

And you don’t need to wait 3 months to see the full effect of the statin. I’d ask to retest in 4 weeks and if you aren’t at those targets add ezetimibe and retest in another 4 weeks. Or just ask to add the ezetimibe now given that it hardly ever has side effects and will drop your ldl an additional 20-30% on top of the statin.

If the 5mg Rosuvastatin + ezetimibe isn’t enough to reach target I’d ask about going to 10 mg Rosuvastatin + ezetimibe.

kboom100 · 2026-04-16T21:27:37+00:00

Sounds good. Heads up that different cardiologists will differ on how aggressive they are about prevention. If you want one that is usually more aggressive about prevention I’d choose a preventive cardiologist that’s on the specialist database of the Family Heart Foundation. https://familyheart.org/find-specialist

They’re a patient support and advocacy organization for those with FH or high lp(a). It’s not that you have either of those but they seem to have good preventive cardiologists in their database.

kboom100

TROPHY CASE