One of the most common questions that patients ask me is why they should take medication for cholesterol. They often don’t have any symptoms of high cholesterol and many people don’t like the idea of taking a medication for something that they don’t feel is causing them any problems. I felt like it was important to write a little bit about cholesterol, triglycerides, goals and treatment options.
So why should you care if your cholesterol is high? Did you know that there are both good and bad forms of cholesterol? What’s the difference between high cholesterol and hyperlipidemia? These are all great questions and I will attempt to answer them in this article.
When we use the term hyperlipidemia, we are generally speaking about the amount of fats in the bloodstream being elevated. Fats include both cholesterol and triglycerides. When the level of fat is elevated in the bloodstream it can collect in your blood vessels and cause blockages.
If you think about your blood vessels as being hoses that feed the different organs of your body, you can imagine cholesterol as a substance which collects or coats the inside of these vessels so that the blood has a narrowed space to flow through. If too much cholesterol fills up in the blood vessels it can make it difficult for the blood to flow through this area and reach certain areas of the body.
If the blood flowing through your body is blocked and cannot get to a certain area of your heart, you could have a heart attack. If blood has trouble reaching an area of your brain, you could have stroke. So how do you know if your blood vessels are being blocked by fats such as cholesterol or triglycerides?
Will you have symptoms? It can be very challenging to know if you are getting fat from cholesterol and triglycerides stuck in your blood vessels. You might not have symptoms until the blood vessels become plugged to such a degree that blood cannot get through. At this time, your heart or brain may suffer permanent damage from a heart attack or stroke. It’s very important to prevent the blood vessels in the body from becoming plugged with cholesterol or triglycerides that we refer to a plaque when it combines with other cells of the body such as platelets.
Why are doctors even more worried about my cholesterol levels now that I was diagnosed with diabetes? Diabetes means that your blood sugars are likely higher than they should be. High sugar within the blood vessels causes damage that makes the inside of the vessels (where the blood flows) become sticky and the cholesterol and platelets stick inside the blood vessels that have been damaged by high blood sugar much easier. Smoking also causes damage (increased stickiness) to the insides of the blood vessels and makes it easier for cholesterol plaque to stick inside the arteries and potentially lead to a heart attack or stroke.
Most of us have heard the terms “good cholesterol and bad cholesterol.” Two difference forms of cholesterol known and LDL (Low density Lipoprotein) and HDL (High Density Lipoprotein) are commonly measured in your lipid tests. We like to see a high level of HDL because this type of cholesterol actually lowers the risk of heart disease and stroke by destroying the plaques that build up within the blood vessels. We like to see low levels of LDL because this type of cholesterol is the bad kind that combines with platelets and sticks inside the blood vessels and can increase the risk for heart attack or stroke. Total cholesterol is a combined measure of both the HDL and LDL cholesterol. You don’t need to fast anymore to be able to measure your cholesterol. There is a direct LDL and HDL test that can be done at your office visit without fasting (only if the local lab offers it). When I’m looking at the patients lab results, I’m more concerned about the HDL and LDL than I am with the total cholesterol because I want the HDL to be high and the LDL to be low.
So what should your cholesterol numbers be? Well that depends on your risk factors for heart attack, stroke, kidney disease and whether you have diabetes. We try to get the levels of LDL cholesterol lower in patients who have diabetes, kidney disease or who have already had a heart attack or stroke.
So how low should you go?
1) For someone who has had a heart attack or stroke: an LDL below 70-80 mg/dL is recommended, especially if they have diabetes or smoke
2) If you have heart disease but do not smoke, have kidney disease or diabetes then we try to get the LDL below 100mg/dL
3) If you do not have heart disease but have risk factors such as diabetes or tobacco use then we try to get the LDL below 130mg/dL
4) If you have zero or only one risk factor for heart disease then we he try to get the LDL lower than 160 mg/dL
The ideal for the LDL has been changing over the years, but in general we now recognize that getting the LDL as low as possible is usually beneficial.
What about the triglycerides? We have some evidence to suggest that elevated triglyceride levels increase the risk of heart disease but high triglycerides have not generally been thought to pose the same risk of heart disease as high LDL cholesterol. We consider normal to be below 150mg/dL, borderline high to be 150-199 and high to be over 200. Triglycerides need to be measured after fasting for at least 12 hours (nothing to eat or drink except water). We usually treat a patient to lower the triglycerides if they are higher than 500-1000 mg/dL, if they also have high LDL, strong family of heart disease or other risk factors.
When should I start getting my cholesterol checked? Most experts believe that you should start getting your cholesterol checked at age 35 in men (if they don’t have risk factors such as
1) High blood pressure
4) Kidney problems
5) Family history of heart disease in a close relative under age 50
6) Family history of high cholesterol
Or at age 20 in men who have any of the risk factors above. Women should get their cholesterol checked at age 45 if they don’t have the risk factors above or at age 20 if they do have any of the risk factors above.
Treatment for hyperlipidemia (High cholesterol/triglycerides):
The decision to treat high cholesterol (LDL) or high triglycerides should be a joint decision with you and your medical provider. There are several possible treatment options and the decision may be better may by use of a Framingham 10-year risk of coronary heart disease calculator (http://hp2010.nhlbihin.net/atpiii/calculator.asp). There is one for women and a separate one for men based on the patient’s age, blood pressure, total cholesterol, HDL cholesterol, whether they are taking blood pressure medication, whether they smoke and whether they have diabetes.
1) Lifestyle changes: Every medical provider has been trained to educate patients that LDL cholesterol can be reduced by reducing total and saturated fat in the diet and losing weight (if you are overweight). In addition, exercising aerobically for 30 minutes a day, 5 days a week (at least) and eating a diet rich in fruits and vegetables can also help reduce the bad LDL cholesterol and increase the good HDL cholesterol.
2) Statins such as Lipitor (also called Atorvastatin), Lovastatin, Pravastatin, Simvastatin, Fluvastatin and Rosuvastatin are usually the first line of treatment for patients with high LDL cholesterol because they work very well for most people. They can reduce cholesterol levels by as much as 20-60%. Statins have also been shown to reduce triglycerides (but they don’t work as well for that as some other medications) and slightly increase the good HDL cholesterol. Some patients have complained of constipation, heart burn or muscle cramps while taking a statin medication. Usually switching to a different statin can help. In addition, you should generally not drink grapefruit juice while taking statins because this increases the risk for muscle cramps or other side effects. We also need to monitor your liver function closely while taking a statin.
3) Zetia is a newer medication which supposedly has fewer side effects than statins and has been shown to lower LDL cholesterol but studies are still ongoing to discover if patients who take this medication daily have fewer heart related problems than those who don’t take it.
4) Cholestyramine, colesevelam and colestipol are bile acid sequestrants that reduce the amount of cholesterol absorbed from food. Some people who take these medications however complain of nausea, bloating and abdominal cramping. Patients taking digoxin or Coumadin need to be careful when taking this medication as they can interfere with each other.
5) Niacin is a B vitamin that can lower cholesterol. It can have an unpleasant side effect of causing skin flushing however. A friend of mine in medical school took a high dose of niacin to help lower his cholesterol after hearing a lecture about it and developed itchy red skin (it got better) because he started out at a dose that was too high too quickly. We usually start taking it at a very low dose and gradually increase the dose along with taking aspirin. Your body becomes acclimated to the Niacin so you don’t have to worry about the skin flushing, itching or tingling after about 10 days. If you forget to take it for a day and then re-start Niacin at the same dose you took it at previously however, you can be in for a rude surprise when the flushing starts again. We don’t usually recommend niacin for patients who have gout because it can cause an increase in uric acid levels.
6) Gemfibrozil, fenofibrate and fenofibric acid or Tricor are a group of medications called “Fibrates”. These medications are good at lowering the triglycerides but don’t help very much with lowering the bad LDL cholesterol. They can help raise the good HDL cholesterol slightly though. Some patients have complained of muscle pain when taking these medications and you need to be careful if you take them at the same time you take a statin because there is more risk of muscle pain and we have to monitor the liver function closely.
Non-prescription treatments for high cholesterol:
1) As I already mentioned lifestyle modification including healthy dietary changes and increased exercise can be beneficial
2) Niacin – see above
3) Fish oil – Eating a diet rich in oily fish such as anchovies or tuna has been shown to help reduce triglyceride levels in some people. There are various companies that make fish oil supplements and most studies have recommended a daily 1 gram fish oil supplement to be tried if you do not eat enough fish.
How often should I have my cholesterol checked? There is no concrete data that tell us how often your cholesterol should be checked once it has been treated adequately with medication or it has been shown to be within acceptable limits. Purposed data suggest rechecking every 5 years for those without heart disease, diabetes or other risk factors. We usually however check cholesterol and liver enzymes for those patients on medication every three months if they are not at their goal and at least once a year once they have reached their goal LDL and/or triglyceride levels.
For more information check out the resources below:
1) Framingham Heart Study: www.framingham.com/heart/
National Cholesterol Education Program of the National Heart, Lung and Blood Institute (NIH): http://www.nhlbi.nih.gov/health/public/heart/chol/cholesterol_atglance.htm
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO