Treating Your Raised Cholesterol Level

Many people think they have their cholesterol levels 'under control'. However, new guidelines
from the US National Heart, Lung, and Blood Institute recommend a much more aggressive
target for lipid levels. The new target is based on calculations of the likelihood of coronary
artery disease in relation to lipid levels. Find out your new target.

Introduction

Most people are aware of the need to check their blood cholesterol from time to time, and, if
necessary, to do something about it. For some time, we have been informed of the epidemic of
overweight and type 2 diabetes in developed countries like the USA. Now the US National
Heart, Lung, and Blood Institute has issued guidelines for managing high cholesterol levels
that set new, more aggressive targets for treatment. If they are followed, the number of US
adults who should be taking lipid-lowering drugs will almost triple.

Here is a summary of the new guidelines, somewhat simplified.

Your cholesterol numbers

Everyone age 20 and older should have their cholesterol measured at least once every 5 years.
It is best to have a fasting blood test called a "lipoprotein profile" to measure your:

• Total cholesterol
• LDL (bad) cholesterol - low-density lipoprotein cholesterol, the main source of
cholesterol buildup and blockage in the arteries
• HDL (good) cholesterol - high-density lipoprotein cholesterol, helps keep cholesterol
from building up in the arteries
• Triglycerides - another form of fat in your blood

The focus initially is on the LDL cholesterol level. Its value is categorized this way:

LDL mg/dL LDL mmol/L

Below 100 Below 2.6 Optimal
100-129 2.6 - 3.3 Near optimal/above optimal
130-159 3.4 - 4.1 Borderline high
160-189 4.2 - 4.9 High
Above190 Above 5.0 Very high

HDL (good) cholesterol protects against heart disease, so for HDL, higher numbers are better.
A level less than 40 mg/dL (1.0 mmol/L) is low and increases your risk for developing heart
disease, while levels above 60 mg/dL (1.5 mmol/L) lower your risk. Triglycerides can also
increase the risk of heart disease; they may require treatment if they continue to be raised (i.e.
above 150 mg/dL, or 1.7 mmol/L) after your LDL cholesterol has been controlled.

Do you need active treatment?

Apart from your LDL level, the major risk factors for coronary heart disease (and stroke) are:

• Cigarette smoking
• High blood pressure (BP above140/90 mmHg, or you are taking medication for high
blood pressure)
• Low HDL cholesterol - i.e. below 40 mg/dL.
• Family history of early heart disease (i.e. heart disease in your father or a brother
before 55, in your mother or a sister before 65)
• Age: men 45 or older, women 55 or older

Here's your target LDL level, depending on how many risk factors you have:

• None, or just one, risk factor: below 160 mg/dL (4.2 mmol/L)
• More than one risk factor: below 130 mg/dL (3.4 mmol/L)
• If you have diabetes or some sort of heart disease: below 100 mg/dL (2.6 mmol/L)

So, what's the plan?

Before deciding this, your physician should make sure there isn't another reason for your
having raised lipid levels. Tests can show if you have diabetes, an underactive thyroid gland,
liver disease, chronic kidney failure, or are taking any suspect medications (progestins,
anabolic steroids, or corticosteroids).

About half those who have to lower their LDL cholesterol levels can reach their target by
changes in their lifestyle, without the need for medication. This approach is called
Therapeutic Lifestyle Changes (TLC) - see link to another article below. The main changes
are:

1. Diet The TLC diet is a low-saturated-fat, low-cholesterol eating plan that calls for less
than 7% of calories from saturated fat and less than 200 mg of dietary cholesterol per
day. You should take only enough calories to maintain a desirable weight and avoid
weight gain. If your LDL is not lowered enough by this, you can increase the amount
of soluble fiber in your diet, and add food products that contain plant stanols or plant
sterols (for example, cholesterol-lowering margarines).
2. Weight Management If you are overweight, losing some can help lower your LDL
and is especially important if you have high triglyceride and/or low HDL levels,
and/or have a large waist measurement (more than 40 inches for men and more than
35 inches for women).
3. Physical Activity Apart from helping in weight loss efforts, regular physical activity
can itself actually improve your cholesterol numbers (30 minutes on at least 5 days a
week, if possible!).
You should have a check-up after 6 weeks on the TLC regime. If your LDL cholesterol level
hasn't improved, intensify your efforts in all three areas, and return in 6 weeks for another
blood test. At this point, your physician may advise you to start a lipid-lowering medication.

Drug treatment

When you start medication you should continue your TLC - this will help keep your drug
dose down (and thus help avoid side effects), and lower your risk of heart disease in other
ways, too.

The likely first choice of drugs will be one of the statins (HMG CoA reductase inhibitors).
These drugs are very effective in lowering LDL cholesterol, and are generally extremely safe.
Recently one statin, cerivastatin (Baycol), has been withdrawn because of a number of cases
of a severe side effect involving degeneration in the muscles, leading to kidney failure. The
other statins available (e.g. lovastatin, pravastatin, simvastatin, fluvastatin, and atorvastatin)
do not cause this adverse effect, or only extremely rarely in a very mild form. Statins can have
other good effects, in addition to their lipid-lowering action - they appear to delay or prevent
heart attacks and strokes.

Other first-line drugs include bile acid sequestrants, nicotinic acid, and fibric acids. Bile acid
sequestrants lower LDL and can be used alone or in combination with statins. Nicotinic acid
lowers both LDL and triglycerides, and raises HDL. Fibric acids lower LDL to some extent,
but are used mainly for high triglyceride and low HDL levels. Your physician will advise you
on the need to use one or other of these drugs, all of which can produce occasional noticeable
side effects.

The prime purpose of treatment is to lower your LDL to its target level. You should have a
check about 6 weeks after starting medication, so that the dose can be adjusted and, if
necessary, another drug added. Once your LDL target is reached, other lipid risk factors (high
triglyceride, low HDL cholesterol) and your non-lipid risk factors (if any) must be addressed.

One important target for therapy is the so-called metabolic syndrome, or syndrome-X, which
represents a mixture of lipid and nonlipid risk factors. The syndrome is diagnosed if there any
3 of the following: waist measurement over 40 inches (men) or 35 inches (women), raised
triglyceride with low HDL, high blood pressure, and a fasting blood glucose over 110 mg/dL.
If you think you may qualify, check the separate article on TLC - see the link below.

Conclusions

It's clear that our knowledge of the risk factors for coronary heart disease has increased to the
point where we can, and should, take more aggressive preventative steps. Adapting lifestyle
changes can, in many cases, help avert both coronary disease and type 2 diabetes. These new
recommendations provide the course of action for you to take charge of one of the major
factors associated with early cardiac death - your cholesterol numbers. You have to provide
the necessary discipline to follow the recommendations.