By Karen Koffler, MD
Cholesterol is more complicated than you think….
The notion that high cholesterol, and in particular, high LDL or “bad” cholesterol drives heart disease is well entrenched in the medical world. Indeed, one of the most prescribed medications, atorvastatin (Lipitor), grossed $150 billion in 2017 because statins have been shown to lower LDL cholesterol. One would think, therefore, that with so many people on this medication, we would see a reduction in deaths due to heart attack. But we do not. In fact, one of my earliest memories of the cholesterol conundrum was when I cared for a 45 year old man admitted to the hospital on Thanksgiving Day because he was having a heart attack. His cholesterol was perfect: 140 and his LDL was not elevated. I remember scratching my head trying to reconcile a “perfect cholesterol” with the fact that he had coronary artery disease. So we have a medication effective at lowering “bad” cholesterol, and heart attacks that happen in people with normal cholesterol. Why the disconnect?
To understand this conundrum, we need to look further.
We make most of our LDL cholesterol- through our liver, but also everycell in the body makes cholesterol. This tells us that cholesterol is very important. It is used to make the structure of every cell membrane, vitamin D, hormones, bile (to degrade and absorb fat), and other functions. It is considered essentialand in fact, very low cholesterol is actually harmful. So to cast it as evil is to forget these critical roles. Why, then, would something with so many important jobs actually turn out to be harmful to us? It is a hard one to answer.
When we look at the arteries of people with heart disease, we do see LDL cholesterol burrowed in to the blood vessel wall, and lots of inflammation in response to this. This is why LDL is perceived as the bad actor in creating heart disease. So we measure this routinely in patients so that we “know” how aggressively to treat.
What science is showing us is that the total number of LDL cholesterol particlesis one of the most important determinants of one’s tendency to develop coronary artery disease. But this lab test is not even ordered by most doctors because the scientific discovery has not yet penetrated medical consciousness. On most cholesterol or lipid panels, LDL cholesterol iscalculated, not directly measured, and we now know, due to improved technology, that calculated is not as accurate. If we value the information that LDL gives us, we need to be sure we are measuring it accurately.
And yet, when we look at some of the studies involving cholesterol, we often see surprising findings. Consider the evidence from the scientific literature:
- More than 50% of heart attacks happen in people with normal But cholesterol fragments are alwaysfound in the lining of blood vessels of patients who have had a heart attack regardless of blood level.
- Some studies are showing that lowering LDL does not consistently reduce risk of death
- People over 70 may actually be harmed by aggressive cholesterol lowering
What else can account for the chronic rise in heart disease? Clearly something else is at play. Turns out, increasingly we see that high blood sugar, created by the typical western diet, drives the liver to create more LDL and more aggressive forms of LDL. In addition, high sugars injure the blood vessel wall which draws the cholesterol in, setting up the inflammation and plaque mentioned earlier. Sugar in all its forms is becoming increasingly understood as problematic as we were led 50 years ago to change to a low fat, higher carbohydrate diet and, as a result, we have seen heart disease (and diabetes) become epidemic.
Other things injure the blood vessel wall: cigarette smoking, hypertension, infections, stress. So, rather than looking at the downstream events, ie, cholesterol in the wall of a vessel, and addressing that simply with drugs that lower cholesterol, it may make more sense to look upstream at thelifestylethat creates the opportunity for LDL to “misbehave” in the first place. Anything that causes inflammation and injury can contribute to heart disease. Therefore preventing inflammation should be our main goal.
In fact, in the prevention of heart attacks, many cardiologists now believe the data for statin use has been exaggerated and that some of its benefits may have little to do with its impact on lowering cholesterol. It might be that its anti-inflammatory properties exert a large effect on protecting the vessel wall from injury.
So, what can you do while medicine continues to sort this out? For one, ask your doc for the latest, most accurate tests: hsCRP, apoB, Lpa, LDL particle number. From this information, we do a better job assessing risk. But also, make sure you get a fasting insulin, fasting blood sugar and HgBA1c with your routine blood work to be sure your dietary carbohydrate intake is not contributing to heart disease.
Keep exercising- this lowers blood pressure and reduces injury, plus keeps you insulin sensitive. Quit smoking and the sugar habit. Learn how to breathe. Cultivate calm. And don’t get overly fixated about your cholesterol numbers. Live an anti-inflammatory lifestyle and you will be giving yourself the best protection you can.
