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Cholesterol and your heart

Cholesterol has turned out to be among the most important of the risk factors for heart disease. Moreover, scientific studies have shown that lowering cholesterol levels dramatically cuts the risk of having a heart attack, developing angina (chest pain), or dying suddenly.


Cholesterol doesn't float around in your bloodstream naked. It's a kind of fat, and fat and water don't mix. So cholesterol is carried within tiny molecules of protein called "lipoproteins" ("lipo" means "fat"). There are several kinds of lipoproteins. The most important are called HDL and LDL.

(HDL and LDL are short for "high-density lipoprotein" and "low-density lipoprotein". The names come from how these proteins were first discovered: if you spin serum in high-speed centrifuges, the high-density lipoprotein is heavier and sinks to the bottom. LDL floats near the top.)

HDL is like "Mr. Clean." It sweeps up molecules of cholesterol wherever it finds them (like inside your arteries) and carries them away. HDL is good for you. (One of my patients remembers that HDL is the good kind by thinking of it as "happy" cholesterol.) The more of it, the better. Enough HDL can protect you from atherosclerosis. Your HDL cholesterol level should be at least 50 -- ideally over 65. Too little HDL (under 40 in men, 50 in women) is bad for you. One of the reasons women develop heart disease later than men is their naturally higher levels of HDL.

LDL, on the other hand, is like "Pig-pen." It carries cholesterol to your tissues, frequently leaving a mess in your arteries. (My patient calls it "lousy cholesterol.") You don't want much LDL, and your LDL cholesterol level should be less than 130. However, if you're at increased risk of atherosclerosis, your LDL should be under 100 -- less than 70 if you're diabetic or have existing heart disease.

To lower your risk of heart disease, raise your HDL while lowering your LDL or total cholesterol.

Of the two, most of our focus has been on LDL, for several reasons. First, medications are much more effective at lowering LDL than raising HDL. Second, though many cholesterol-lowering drugs raise HDL, so far the science hasn't proven that targeting HDL levels lowers your heart disease risk. Finally, a sufficiently high LDL level (200 or more) swamps all other heart disease risks and should be treated regardless.

Your level of HDL is largely hereditary, but all sorts of things influence it. You can improve your HDL by stopping smoking, losing weight, and exercising.

Estrogen raises HDL, but taking estrogen ove age 60 slightly raises heart disease risk.

Your LDL level is partly determined by hereditary, and it goes up if you are diabetic. But it is also quite sensitive to the amount of animal fat in your diet. Vegetable fat lowers LDL.

Triglycerides are another form of fat in the blood. Butter, margarine, lard, and vegetable oil are all triglycerides. Though not as critical as HDL and LDL cholesterol, extremely high levels should be treated. And elevated triglycerides are one of the hallmarks of diabetes and metabolic syndrome.

What to do now

Here's how to lower the "bad" LDL cholesterol and raise the "good" HDL:

1. Cut down on animal fats. Many Americans are "grease-oholics." They put grease on everything: butter, margarine, mayonnaise, cheese, tartar sauce, shortening, etc. Meat and dairy fat are the worst. We're like the guy who pours catsup all over his food without tasting it, just from habit. Not true for you? When was the last time you had a piece of bread without smearing it with butter? Grease is an acquired taste, one that's not hard to break. But substituting simple starches and sugars for animal fat is like jumping from the fat into the fire. Too many "carbs" increase triglyceride levels, cause weight gain, and can lead to diabetes.

Eating vegetable fat (particularly olive oil) lowers LDL and raises HDL. But beware of "trans" fats and other hydrogenated vegetable oils: they're even worse for you tha animal fats. Thankfully the FDA has ruled that trans fats must be removed from processed foods.

2. Improve your diet. Eliminating junk food and processed foods and having 5-9 servings a day of fresh fruits and vegetables also lowers the heart disease risk dramatically.

3. Stop smoking. Quitting raises your HDL.

4. Daily exercise improves every aspect of cholesterol metabolism. Study after scientific study shows that regular exercise may be the single most important thing you can do to improve your health (aside from stopping smoking). Exercise cuts the risk of virtually every illness by 50%.

5. Take medication. Overwhelming scientific evidence shows that medicines to lower cholesterol reduce the risk of heart disease, heart attacks, and death. They are safe and work wonders. Many other medications also lower heart disease risk, even though they don't affect cholesterol levels directly.

Which cholesterol-lowering medication?

"Statin"drugs have proven spectacularly effective at lowering cholesterol safely. As your cholesterol levels improve, your risk of heart disease and strokes drops as well. Older statins (lovastatin, fluvastatin, pravastatin, and simvastatin) don't lower cholesterol as much as the newer atorvastatin (Lipitor) or rosuvastatin (Crestor), but they work well if your risk is intermediate. Except for Crestor, all these statins are now available in generic form at substantial cost savings.

Statins have few side effects and are easy to take. But a very small percentage of people who take them develop liver abnormalities or muscle damage, so you should have a blood test a few times a year while taking a statin. A very small number of people have had serious muscle injury from statins, particularly if they are combined with other drugs we know now not to use. If especially severe, muscle injury can lead to kidney damage.

Statins may increase your risk of developing diabetes. Despite this, they are so effective at lowering your risk of other illnesses that your overall health risk improves.

Minor muscle aching occurs in 10-20% of patients. Some statins are more apt to cause this side effect than others. Many people find that taking coenzyme Q10, an over-the-counter supplement, relieves this minor aching. Take 100 mg. three times a day.

When they hear of the risks and side effects, many people are reluctant to take statins, even though the vast majority of patients never have a problem. I use the analogy of seat belts. Most of us have heard the tales of people whose lives were saved by being thrown free from the car during an accident, just before the car blew up. But all those people who were killed by not wearing seat belts aren't around to tell the tale. Your risk of being killed by a seat belt in an accident is 17 times less than the risk of not wearing one. That's a no-brainer: you're vastly safer wearing seat belts.

In the same way, study after scientific study has proven the benefits of statins: not just lowering cholesterol but saving lives and reducing heart attacks and other cardiac events. If you're at risk, it's no-brainer.

Zetia (ezetimibe) blocks absorption of cholesterol from the intestine. It rarely causes side effects and seems quite safe. Though it drops cholesterol substantially, we are only now seeing scientific studies showing it lowers risk of heart disease. Ezetimibe combines well with "statin" drugs. Indeed, Vytorin is a prescription combination of ezetimibe with simvastatin.

Tricor (fenofibrate) lowers triglycerides and raises HDL. Unlike Lopid, an older drug in the same family as Tricor, it is safe to take with statins and causes fewer side effects. But it doesn't work nearly as well as a statin, and adding it to a statin provides no benefit. Fewer doctors are currently prescribing it.

Fish oil developed a reputation as a good way to lower cholesterol and triglycerides. Recent studies have shown no effect on heart disease risk, and it's now rarely used.

Plant stanols are herbal supplements you can get without a prescription. Like any herbal product, be sure to get good quality. I often recommend the Nature Made brand Cholest-Off. There are few risks with this supplement, and some of my patients have found it helpful in reducing cholesterol. But to my knowledge, no scientific studies have been done that show this herb reduces heart disease or death.

Last updated Fri, Jun 19, 2015

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©2011, James Gagné, MD