# Healthspan Priorities - What to Flag

Quick reference for what to surface from medical documents. Tula uses this to decide what's actually worth Paul's attention vs. routine noise.

## Tier 1 - Always Flag

These move the needle on healthspan and are often missed in routine "everything looks normal" readouts.

### Cardiovascular
- **CAC (coronary artery calcifications)** - any mention. Quantify if not already (Agatston score).
- **apoB** - primary atherosclerotic risk marker. Optimal: <80 mg/dL primary prevention, <60 mg/dL with established disease/diabetes.
- **Lp(a)** - once-in-a-lifetime test. Elevated (>75 nmol/L or >30 mg/dL) changes the risk model entirely.
- **LDL-C, non-HDL, triglycerides, HDL** - context for apoB.
- **hs-CRP** - >2 mg/L = inflammatory burden.
- **Coronary calcifications mentioned in any CT chest** - even "mild" - note the patient is in the atherosclerotic process.

### Metabolic
- **HbA1c** - optimal <5.4%. 5.7-6.4% = prediabetes, ≥6.5% = diabetes.
- **Fasting insulin** - most miss this. Optimal <8 µIU/mL. With glucose, compute HOMA-IR = (glucose × insulin) / 405. Optimal <1.5.
- **Triglyceride/HDL ratio** - proxy for insulin resistance. Optimal <1.5 (mg/dL units).
- **Hepatic steatosis** mentioned anywhere on imaging - fatty liver = MASLD/NAFLD = metabolic warning.

### Liver
- **ALT >30 in men, >19 in women** - hepatologists treat older "normal" cutoffs (40-55) as too lax. ALT > AST with elevated GGT in steatosis.

### Kidney
- **eGFR <60** - CKD signal. Trend matters more than single value.
- **UACR** - proteinuria. Most sensitive early renal damage marker.

### Hormones (men)
- **Total testosterone <400 ng/dL** - symptomatic hypogonadism territory.
- **DHEA-S, IGF-1** - age-decline markers, optional.

### Vitamins
- **Vit D 25-OH <30 ng/mL** - common, easy fix, cardiometabolic + immune impact.
- **B12 <400 pg/mL** - even within "normal" 200-900, low end is suboptimal especially over 50.

### Cancer screening flags
- Any nodule >6mm in lung, kidney, liver, thyroid → follow-up protocol depends on Fleischner / size / location.
- PSA velocity matters more than absolute value.

## Tier 2 - Worth Mentioning

- Hepatic steatosis mentioned on imaging → metabolic workup.
- Coronary calcifications even when "mild."
- Diverticulosis → fiber/hydration counsel, not urgent.
- Skin/subcutaneous nodules - note for tracking, generally cosmetic.
- Degenerative spine changes - age-appropriate above 40, mention only if pain or progression.

## Tier 3 - Note But Don't Lecture

- Pulmonary intrapulmonary lymph nodes (tiny fissural nodules) - benign.
- Simple renal/hepatic cysts - benign.
- Mild splenomegaly or hepatic granulomas - context-dependent.

## Comparison Logic

When new results arrive and prior values exist in memory:
1. Compare directionally - improving, stable, worsening.
2. Flag any >20% change in: apoB, LDL, triglycerides, HbA1c, ALT, GGT, hs-CRP, fasting insulin, eGFR.
3. Flag any new abnormal result that was prior-normal.
4. Flag any newly-resolved abnormal - celebrate progress.

## Things NOT to Do

- Don't make medical decisions. Surface findings + suggest discussions with provider.
- Don't recommend specific drugs or doses.
- Don't catastrophize. "Mild" findings are often actionable, not alarming.
- Don't bury the lede. If apoB is 130, lead with that, not "your sodium is 140."
