It seems as if we never hear enough about elevated cholesterol and the risk of heart disease.  To remind us of such, September of every year is designated as National Cholesterol Education Month. 

There remains a lot of controversy as to how important cholesterol is as an independent risk factor. There are a lot of radical folks out there that simply decry the role of elevated cholesterol in heart disease. They want you to believe that it’s all a hoax. Traditional cardiology, on the other hand, cites the literature and argues that this problem is of epidemic proportions; that lower is better.

Who to believe? Hopefully as The Medical Advocate, I can help clear the air. As an integrative cardiologist practicing functional medicine, I examine everything, both mainstream and “out of the box” thinking.

For the record, cholesterol is clearly a major risk factor for heart disease. It’s right up there with hypertension, smoking, diabetes, obesity and physical inactivity. Cholesterol is a significant component of arterial plaque. Decades of scientific research can’t erase that fact.

The question is the importance of the actual numerical value. Currently it is believed that a value over 200 for total cholesterol and over 100 for LDL ( the lousy cholesterol) is too high. But these are very general guidelines and don’t take into account the individual patient.

Let’s first focus on secondary prevention; that includes folks who have sustained a previous cardiac event such as a heart attack or stroke .Also included are those who have had a previous balloon angioplasty/stent or coronary bypass surgery. These individuals are clearly high risk, and we know from the scientific literature (4 S STUDY and more from the 1990’s) that treatment with statins prevents further events.

Also included in this high risk class are diabetics. Since 70% of diabetics will experience a heart attack or stroke in their lifetime, we generally treat them as if they actually have coronary heart disease.

On the contrary, primary prevention refers to individuals with elevated cholesterol who have never experienced an event, those without known coronary disease.

Those of you who know me can attest to the fact that I am not a statin pusher. I rarely, if ever use statins for primary prevention. In these individuals, I generally exhaust lifestyle measures and use supplements when appropriate (e.g. red yeast rice supplement, tocotrienols, and citrus bergamot to name a few).

However, when it comes to secondary prevention, I employ whatever necessary to achieve goal. This is when I follow the accepted science. 

However, I disagree with the current trend that lower is better. This thinking has come about by the introduction of a new class of meds, the PCSK9 inhibitors. These are biologics that interact with the LDL receptor in the liver. Injected subcutaneously twice a month, they can lower LDL cholesterol by a whopping 55-75%. So by adding statins to this class of meds, we can now achieve LDL levels in the 20’s or lower.

How good is this? Proponents quote a couple of short term studies. They say this poses no risk to the patient. However, we know nothing about the long term effects of levels this low. What about having LDL levels below 40 for 10-20 years?

Let’s not forget that cholesterol is far from being a villain. It’s essential for life. It’s vital for the formation of bile acids, sex hormones, vitamin D, and myelin sheaths protecting nerve cells in the brain. Cholesterol also plays a role in formation of new nerve cells.

I, for one, am very concerned with the long term effects of very low levels of LDL. I mean, who wants a healthy heart with a lousy brain?! 

Moving on, there is more to look at than the actual numerical values. Regardless of whether we are talking about primary prevention or secondary prevention, we need to know more than the actual LDL value. We need to look at the actual size of the LDL particle. Although many cardiologists fail to measure this,   it’s an important aspect of blood lipids (fats). All you need to remember is that bigger is better! 

Large fluffy LDL is much more stable the small dense LDL. Small particle size is 40% more likely to get oxidized than large particle size. Why is this important? Once LDL becomes oxidized, it is more likely to enter the arterial wall. This starts the inflammatory process and the end result is plaque.

So it’s not merely LDL that is the problem, but  small dense LDL that has become oxidized. What you need to ask for is LDL particle sub-classification. This can be measured by Boston Heart Labs, or Cardio IQ by Quest Diagnostics (formerly Cleveland Heart Lab).

This distinction is important because the treatment is different. Statins may do a good job at lowering LDL, but they do nothing to actually change the size of the LDL particle. Niacin, on the other hand, can convert a small particle into a large particle. Avoiding trans fats and a high carb diet can also help in this regard.

Another important lipid particle is Lp(a), which is actually a fragment of LDL cholesterol. This is generally genetically determined and is often seen in individuals with a strong family history of coronary disease. It, too, is not generally measured but you can ask for it. Lp(a) is very sticky and inflammatory and clearly increases the risk of coronary disease. Statins, diet and exercise won’t lower Lp(a),however, niacin can in many cases.

Do you get my drift here? Indeed LDL cholesterol remains a major risk factor for heart disease, but we need to know more than the actual numerical value:

• Are we talking about primary or secondary prevention?

• Is it large fluffy size LDL or small dense particle size?

• Is there elevation in Lp(a)?

Remember that cholesterol is but one piece of the pie. The reason why you hear so much about it is because it’s a money maker! We have drugs that can deal with this problem quite nicely. However, don’t forget the role of diet, supplements and exercise.

Lastly, I always end this discussion by saying, “Your cholesterol level is one thing, but what I really want to know is do you have any inflammation going on?” Cholesterol becomes an issue only when inflammation is turned on. 

Inflammation initiates plaque formation.  You should have your C reactive protein (CRP) level checked often. CRP is a non-specific marker for inflammation. Inflammation doesn’t bode well for healthy aging.

My hope is to give you a perspective on cholesterol and how it relates to heart disease. Since the focus is on cholesterol, the numerous other risk factors were not included at this time

Remember that lower is not necessarily better; the important thing is to know your individual risk of heart disease.

As a Medical Advocate your job is to stay in the driver’s seat when it comes to your health.

Yours in health,

Howard Elkin,MD The Medical Advocate