Silent Killers: Cholesterol

The second topic in the series of Silent Killers is cholesterol. Luckily, my very good friend and partner, J. Kevin Bridges MD is one of two certified Lipidologists in the state of Mississippi. JKB knows A LOT about cholesterol, so who better to be my first guest blogger?! The words below are straight from the lipid guru himself.

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What is high cholesterol?

• Cholesterol is made by your body normally, and it is also consumed in the foods you eat.

• Your body needs cholesterol for proper cellular function.

• When we say your cholesterol is high that can mean several things, as there are other parts of your cholesterol panel (aka lipid panel) that we use to determine your cardiovascular risk. Examples are triglycerides and different lipoproteins (LDL, HDL, etc).

• Each of these components can be “high” when compared to the rest of the population, so it’s not always as simple as saying your cholesterol is high.

Why does it matter if my cholesterol is high?

• What we know for certain now is that if certain parts of your cholesterol/lipid panel are high, then it increases your risk for cardiovascular events like heart attack and stroke.

• We have proven that by reducing some components of your lipid panel, that there are significant reductions in the risk of heart attack and stroke.

What number is the most important number?

• There has been a lot of discussion and confusion about this over the past few years. The best evidence shows that the most important number in your lipid panel that we can use to predict your cardiovascular risk is a value called “non-HDL.” This number is your total cholesterol minus HDL (high density lipoprotein).

• In reality, this number confuses some people, so it is generally easier to focus on LDL (low density lipoprotein).  LDL is what makes up the majority of non-HDL so it is generally accepted that LDL is an easier target of focus for patients and physicians to discuss.

What about my “good” cholesterol?

• HDL (high density lipoprotein) has been described as “good cholesterol”.

• In the past we thought that if we increased HDL with medications that it would reduce your risk of a heart attack or stroke. We know now that this is not true.

• If does seem that many who have a higher HDL naturally have less incidence of cardiovascular events when compared to those who have a low HDL, but this is not universal, as there are certain groups of people who have extremely low HDL and yet they do not have heart attacks or strokes.

• Bottom line about HDL is that we don’t yet fully understand its role in determining cardiovascular risk.

Ok, my cholesterol is high. What can I do to lower it and reduce my risk of a heart attack or stroke?

• The first thing that everyone should do is to re-evaluate your lifestyle (diet and physical activity. Most of us can improve on the foods we eat.

• The latest evidence shows that if we use a 9 inch plate to help with portion control, and if ½ of our plate non-starchy vegetables of a variety of colors, ¼ of our plate is lean protein (fish or chicken), and about ¼ of our plate in whole grains and starchy vegetables, then this is the best overall dietary change one could make to help reduce their risk.

• If you are overweight, you need to lose weight by not only dietary changes, but you need to start doing some moderate aerobic exercise (brisk walking will do). The current recommendation by the American Heart Association is 30 minutes per day, 5 days per week. You may not be able to start off doing this much, but work your way toward this goal.

• If you are smoking, make up our mind that you need to stop and ask your primary care physician to help you achieve this goal, possibly with medications if you struggle to quit on your own

• Once you’ve made lifestyle changes, there are medications that have been proven to lower your LDL (bad cholesterol), while reducing your cardiovascular risk. This is a discussion that you could start with your primary care physician.

Ok doc, I’ve heard about those cholesterol medications and I’ve heard that they are bad. What’s the deal?

• There is a lot of urban legend out there about cholesterol medications. There have been multiple studies that have proven the safety of the drugs that we use today.

• Looking at every one of the landmark clinical trials that have looked at statins in particular, they have all demonstrated a very low incidence of side effects and all have shown to reduce LDL, and subsequently a reduction in cardiovascular events.

• Because of this tremendous amount of data that shows that statins are safe, and they are very effective in lowering LDL (again, this lowers your risk of a heart attack or stroke), statins should be first line drug therapy for someone who has a high LDL and is considered to be at an increased risk for cardiovascular events. Again, you should talk to your doctor about this.

But, I’ve heard that statins make you hurt. I don’t want to hurt.

• There was a study done that put people into 2 groups. One group of people was given the maximum dose of atorvastatin (a statin drug), and the other group was given a placebo (just a fake pill). Neither group knew which pill they received. The study was intended to see if there was a difference in the two groups regarding muscle/joint pain. The study showed that the group that received the statin had about 9% of the people in that group with those reported side effects. The placebo group reported about 6% of their group with the same symptoms. There was not enough difference in the two groups to help demonstrate why the people in the study had these symptoms.

• There is a very small risk of statins causing myalgia (muscle pain) and in very rare cases, myonecrosis (muscle tissue damage). Understand that these are potential adverse effects. This does not mean that you will have these issues. This is not unlike the potential adverse effect of severe liver damage when one takes Tylenol (which millions of people take every day).

• Bottom line is that if you are at an elevated risk for cardiovascular events due to an elevated LDL, then you should not reject the idea of a taking a statin based on what you’ve heard others say. Have that discussion with your primary care physician.

Are there other medications that can help lower my cholesterol, other than statins?

• Yes. It depends on your situation, but there are other medications to help lower your cholesterol; however, you want to make sure that the medication that you are going to take has actually been shown to reduce your risk of cardiovascular events in the case of a high LDL. Regardless, because of their documented safety and cardiovascular risk reduction, statins should be the first drug therapy that should be considered in almost every case. Again, you should discuss this with your primary care physician.

What do I do if my primary care physician and I have difficulty coming up with an effective way to lower my cholesterol?

• There are other resources that you can use to help. You can seek out a clinical lipidologist (someone who specializes in managing complex lipid disorders) with the American Board of Clinical Lipidology at lipidboard.org or with the National Lipid Association at lipid.org

• You could also seek out a cardiologist or endocrinologist interested in managing lipid disorders.

Dr. J. Kevin Bridges MD is one of two board certified lipidologists (one who specializes in cholesterol metabolism) in the state. He received his undergraduate degree in Biology at Mississippi College, completed medical school at the University of Mississippi School of Medicine, then went on and did his Internal Medicine residency at the University of Mississippi Medical Center. He was awarded the Gold Humanism award, which honors students and residents with excellent bedside manner and clinical skills. He was also awarded Evers Society Resident of the Year by the medical students during his third year of residency.

He is also a pretty decent baby sitter.

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