The Skinny on Cholesterol

What’s New? What’s old? What’s important?

September is National Cholesterol Education Month and I am not going to neglect the opportunity to update my Medical Advocate followers on what they need to know to make informed decisions regarding this often bewildering health issue.

The basics you already know. Yes, high-density cholesterol (HDL-C) is the so-called healthy cholesterol, and low-density cholesterol (LDL-C) is essentially the lousy cholesterol. You’ve also been taught to believe that the lower the better as it relates to LDL-C. Furthermore, the higher the HDL level is, the more salubrious.

It never ceases to elude me that mainstream medicine, and mainstream cardiology for that matter continues to preach how crucial it is to get that LDL-C as low as possible. Is it because we have medications that do this quite nicely?

Now don’t get me wrong. I’m not here to be a statin basher. I happen to use medications when appropriate for high-risk patients, where the data is clear. I’m just against overstanization where it’s not needed.

My point is not HOW LOW CAN YOU GO with your LDL-C. It’s more about WHAT IS YOUR ACTUAL RISK?

Who’s considered high risk?

Obviously, people with known documented coronary artery disease (CAD). Such folks have or have had the following:  

• Previous heart attack or stroke

• Previous coronary intervention (by-pass surgery or balloon angioplasty/stenting)

• Documented carotid artery disease and peripheral artery disease (PAD)

The above constitutes the obvious. But there are a couple of other conditions that should raise an eyebrow:

• Diabetics: 70% of diabetics will experience a heart attack or stroke in their lifetime, often with unusual symptoms or no symptoms at all. I treat diabetics as if they have CAD.

• Patients with CAD detected by coronary artery calcium scan; a test I commonly order to stratify my patients as to high risk, low risk or somewhere in between.

I believe that treating these folks aggressively is essential. Why? CAD is a progressive disease. There really is no room for conservative management. Employing and exhausting lifestyle is always my modus operandi. When necessary, I add medications which often include statins in this high-risk group.

My goal is to prevent further progression of disease, to hopefully prevent recurrent events, and repeat trips to the cardiac cath lab! The data is clear. The total cholesterol in these patients should be less than 100 and the LDL-C in the 60-70 range.

Now a lot of my cardiology colleagues are combining statins with a new class of drugs to get even lower levels, with LDL-C in the 20 range. These are biologics administered subcutaneously twice a month. These are known as PCSK9 inhibitors. They have their place and I have quite a bit of experience with them in selected patients.

A word of caution here. LDL-C should not be vilified. It’s what transports cholesterol to the brain, which is essential for myelin sheath production, and for the production of new neurons (nerve cells).

I don’t know about you, but the last thing I want is a good heart with a bad brain!

There are a couple of other factors you need to consider:

• LDL particle number — Most agree that this measurement is more accurate and portends a worse prognosis that simply LDL-C.

• LDL particle size — You only need to remember this: BIGGER IS BETTER. The smaller the LDL particle, the more likely it is to get oxidized and form plaque in the coronary arteries, carotids, and peripheral arteries.

• Lp(a) — This is a fragment of LDL-C, and when present it indicates a high-risk individual, as Lp(a) is extremely sticky, inflammatory and atherogenic (plaque-forming)

The above tests are not standard tests ordered by most physicians, including cardiologists. You need to seek out integrative cardiologists familiar with such testing as obtained by Boston Heart Diagnostics and Cleveland Heart Labs.

What about HDL-C? Should we even care about that? I think so. For years we thought that the higher the HDL-C, the more protective the patient was with regard to CAD. But early trials with pharmacologic agents that increased HDL-C yielded disastrous results. The level of HDL might have risen, but the patients fared poorly. All such trials were abandoned.

HDL-C does have an important role in what is known as reverse cholesterol transport, in bringing excess cholesterol back to the liver for disposal. However, bigger is not necessarily better. The ideal numbers seem to be between 60-80 mg/dl. An HDL of 100 mg/dl is no longer considered protective or desirable.

What’s new is that we are now learning about HDH functionality which may prove to be more important from a prognostic standpoint than the HDL level itself.

Now if you know me, I constantly preach that cholesterol is but one piece of the pie. There are many other risk factors that need to be examined in stratifying one’s risk. I discuss this in detail in my upcoming book: FROM BOTH SIDES OF THE TABLE: WHEN DOCTOR BECOMES PATIENT. So please stay tuned!

What about the masses of folks that are treated with cholesterol-lowering medication who are not high risk? I personally refrain from treating such patients with drugs. Again, I exhaust lifestyle, and often employ supplements that can well make a difference.

So, remember before your medical provider prescribes a statin to lower your LDL-C, make sure you know your risk. The last thing you should do is take a drug that you do not need with the accompanying expense, and adverse side effects.

IT’S NOT ABOUT HOW LOW YOU CAN GO — BUT — KNOWING YOR ACTUAL RISK

Yours in Health,
Howard Elkin, MD

Please join me on Thursday September 20 at 7:00 pm PST on my YouTube channel for a live presentation of the above, with plenty of time for questions and answers.
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VERY IMPORTANT NOTE / DISCLAIMER: I am offering—always—only general information and my own opinion on this blog. Always contact your physician or a health professional before starting any treatments, exercise programs or using supplements. ©Howard Elkin MD FACC, 2021.