Medical staff health column

Almost everyone has heard about the dangers of high cholesterol. It plays an important role when it comes to the development of heart disease. Heart disease, described simply, increases your risk of having heart attacks, strokes and other vascular problems.

Cholesterol, like high blood pressure, is one of the "silent killers." Symptoms are often not present until a person’s health has significantly deteriorated.

There are different types of cholesterol in the body, such as low-density lipoproteins (LDL), high-density lipoproteins (HDL), and triglycerides.

LDL cholesterol is particularly important. It can lead to the formation of plaque in the blood vessels in your body. When LDL levels in your blood get too high it starts to form fatty streaks on the walls of your arteries. These fatty streaks can harden over time, forming plaques, which reduces blood flow through the arteries.

This looks a lot like sludge building up in the pipes of your house. Although these plaques can cause problems throughout the body, one of the major areas of concern is when they form inside the arteries of the heart. These plaques can also become unstable, and tear away from the wall of the artery, which is how heart attacks occur.

Low levels of LDL help to prevent this build up and reduce your chances of developing heart disease. LDL isn’t the only thing that affects your chances of developing heart disease.

There are numerous other risk factors, such as smoking, obesity, diabetes, high blood pressure, genetics and lack of exercise. Some people have an inheritable form of high cholesterol, known as familial hypercholesterolemia, which drastically increases their level of cholesterol. Addressing some of these unhealthy factors in your life helps reduce your chance of developing heart disease, as well as other diseases, like diabetes.

Medication may be necessary to reach healthy levels of LDL cholesterol for people who are unable to achieve these goals through lifestyle changes. Generally speaking an LDL level less than 70 milligrams per deciliter reduces your chances of developing heart disease, while levels above 160 mg/dl are considered to be high risk.

However, your doctor may target different goals for your LDL cholesterol, depending on other factors, such as age, history of diabetes, or history of strokes or coronary artery disease.

New guidelines were released in 2018 by the American Heart Association to help guide clinicians in choosing cholesterol management strategies. These new guidelines are a revision of previous guidelines published in 2013, and help to address some of its shortcomings. Some of the changes include increased emphasis on lifestyle, risk assessment improvements, and more strict control for those in high risk categories.

Risk assessment is performed by using a "cardiovascular risk calculator" that determines your 10-year risk of having a stroke or heart disease based off of your age, blood pressure, cholesterol levels, history of diabetes and history of smoking. Generally, a calculated score of less than 5 percent is considered low risk, while high risk is above 20 percent. However, each patient may have a different view of what constitutes low or high risk.

A brief summary of the latest recommendations are provided below:

1). First and foremost, strive for a healthy lifestyle. This includes a heart healthy diet, plenty of exercise and avoidance of smoking and too much alcohol.

2). Patients who have already had a heart attack, stroke, or other vascular problems should try to achieve as low of LDL cholesterol levels as possible. No studies have found adverse effects with levels of LDL cholesterol below 40 mg/dl, but the harms of LDL levels above 70 mg/dl in this group are well-documented. Statins are generally the first choice of medications used to reduce LDL cholesterol. Statins are well-studied, and have been in use for a long time. They help to reduce inflammation in the body’s blood vessels, and lower the amount of LDL cholesterol in your blood. However, if statins are unable to reduce LDL cholesterol less than 70 mg/dl in high risk patients, then it is important to add additional medications, such as ezetimibe, or PCSK9 inhibitors. If you’ve already had a heart attack or stroke, it is likely that plaque buildup in your arteries was responsible, and it is critically important to prevent that buildup from occurring again.

3). People with very high LDL levels, greater than 190 mg/dl, or familial hypercholesterolemia, should try to reduce their LDL levels early in their life. Although it may not be possible to reduce LDL levels to less than 70 mg/dl in this group, it is important to strive for values under 100 mg/dl.

4). Patients with diabetes should target LDL levels less than 70 mg/dl. Diabetes places people at an increased risk for heart disease and strokes, which makes it very important to keep LDL cholesterol levels low.

5). A 10-year cardiovascular risk factor calculator can be used for those who are older than 40 years and have LDL levels less than 190 mg/dl. Generally speaking those who have a risk greater than 7.5 percent should be placed on a statin.

However, in patients who are uncertain whether to begin taking medication to reduce their cholesterol, they may consider a coronary artery CT scan. This type of CT scan can calculate the amount of calcium buildup in your coronary arteries, which provides an estimate of a patient’s risk of developing heart disease. A score of 0 represents low risk, while a score greater than 100 shows higher risk.

Remember, "Prevention, prevention, prevention." It is always better to adopt healthy lifestyle choices and avoid problems before they start. However, if you are unable to avoid high levels of LDL cholesterol, it is critical that you take steps to avoid developing heart disease. Talk to your doctor about having your cholesterol and cardiovascular risk score calculated.