Lean Docs Talk: Cholesterol and Statins

by Dr. Karl Nadolsky

A common question we get asked by patients and friends is whether or not they need to lower their cholesterol and/or take a statin. It is quite a complex topic since there is a massive amount of research that has been done … and it just keeps coming! As clinicians we have to dive into the data and interpret it to treat our patients to the best of our ability. We decided to make a little video to talk about it. I will list the key points below.

• It isn’t cholesterol itself that contributes to heart disease, it is the specific lipoproteins carrying the cholesterol (e.g. LDL, etc).
• So is LDL the “bad” cholesterol? It is complicated, but in general the higher your LDL-c the higher your risk of heart disease.
• But, it really depends on other risk factors. Have you had a heart attack in the past? Do you have known coronary artery disease or an equivalent (diabetes, peripheral artery disease, etc)? Do you smoke? What is your age and gender? Are you lean and in good physical condition? Do you have high blood pressure? Very importantly, what is your family history? Etc..
• Having a high LDL-c in isolation generally doesn’t give us enough information.
• You can calculate your risk with one of the many calculators – Framingham Risk or Reynolds Risk Score
• One significant problem is that usually the lab test shows the LDL-c, which is the amount of cholesterol carried by the LDL. There is a new marker that looks at the number of LDL particles called LDL-p.
• The higher your LDL-p, the higher your risk of coronary disease but it still depends on all the other risk factors too.
• A cheaper way to see risk is to calculate your Non-HDL which is just total cholesterol (TC) – HDL-c. This gives similar data to the LDL-p by equating to all the “atherogenic” lipoproteins.
• We reviewed the book, The Great Cholesterol Myth – by Jonny Bowden and Stephen Sinatra
• The overall theme of book is pretty good with getting to the root cause of heart disease, which is inflammation/oxidation of the LDL particles / cholesterol along with the other “atherogenic” lipoproteins.
• There were a couple of things that were either outdated/wrong. They mentioned the only thing that mattered was the size of the LDL-p that mattered (Bigger the better, smaller the worse). Size does matter but it really comes down to the more particles being worse off. Also some of their reasoning for LDL-c not being a “risk factor” was off based upon our best evidence.
• For instance they mentioned the ENHANCE trial which put a statin vs. a combo of a statin plus another drug that lowered cholesterol.  Their argument was that the trial showed no difference in carotid intimal media thickness (CIMT) between the groups. CIMT is a marker for atherosclerosis. However, what was not studied was hard end points like mortality or cardiovascular morbidity. A new trial will be ending this year to try to prove that one way or the other (IMPROVE IT trial)
• If you have high LDL-c or LDL-p then make sure you don’t have hypothyroidism and also be sure you don’t have something genetic going on like familial hypercholesterolemia.
• So if we had a healthy patient with no risk factors who only had a mildly high LDL-c what would we do? We would likely make sure diet and exercise were in order and the patient was lean and physically fit. We would also make sure they didn’t have hypothyroidism or a familial condition. From there we would focus on dietary optimization like fiber, monounsaturated fats, etc. (A large topic for another day).
• So then what about at which point would we start a statin or other lipid improving drug? It really depends. We may try testing again in a few months since the lab tests themselves can vary by quite a bit.
• Either way it is important for you to speak openly with your own physician whether you need to lower your LDLc/LDL-p or non-HDL-c. Create a teamwork relationship with your personal physician, and most importantly, optimize your health by “living lean” and using appropriate medications as indicated.

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