Cholesterol: How Low Should You Go?

WebMD Live Events Transcript

If you thought your cholesterol numbers were low enough, check again. A recent report urges a new low in LDL cholesterol numbers for those at high risk for heart attack and stroke. We found out who this news affects, and what you can do to lower your cholesterol, when WebMD in-house expert Brunilda Nazario, MD, joined us on July 14, 2004.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome once again to WebMD Live, Dr. Nazario. Please give us a quick rundown of what new cholesterol goal is being recommended, and who is endorsing these guidelines.

NAZARIO:
The new guidelines are a revision of the recent guidelines set by the National Cholesterol Education Program. These guidelines are endorsed by the National Heart, Lung, and Blood Institute, American College of Cardiology, and the American Heart Association. The update actually points specifically to high-risk and very high-risk patients, or patients at high and very high risk for cardiovascular disease.

In a nutshell, they basically lowered the target goal for "bad" LDL cholesterol, where as previously that goal was set at less than 100 for patients at high risk for heart disease. That goal has now been revised and set to less than 70 for patients at a very high risk of heart disease.

The other point of revision is that it is now recommended that cholesterol-lowering drugs be started at a lower level. What this means is that if you have a patient at high risk of heart disease, in the past if their cholesterol was greater than 130 one would start cholesterol-lowering drugs to bring that LDL to less than 130. The new revision now lowers the threshold at which to start lipid-lowering drugs. It now states that a person at high risk for heart disease should start medical therapy or drug therapy with lipid lowering drugs if they have a bad cholesterol level greater than 100, rather than 130.

In the simplest of terms what the guidelines have stated is that if you are started on a lipid-lowering drug, what is attained should be a drop in your bad cholesterol of 30% to 40%.

MODERATOR:
Is that LDL level of 70 attainable by diet and exercise alone?

NAZARIO:
These guidelines are not intended to take away from the importance of diet and exercise. What is known as TLC, or therapeutic lifestyle changes, are always endorsed in patients at high risk. There have been no trials that I'm aware of that have looked at diet alone as a therapy to lower cholesterol down to those levels. As a matter of fact, since the recent guidelines, not the revisions we're talking about today, but since the recent guidelines in 2001 there have been five new studies looking at intensive cholesterol-lowering drugs. Previous clinical studies on LDL levels that low have not existed, which is why these guidelines are being revised.

There have been other types of studies that have looked at very low levels of LDL as a coincidental finding. These studies had "suggested" that extremely low levels of LDL are associated with an increased risk of death, especially strokes. Having said that, this is not scientific proof. These were not controlled studies. But the more recent studies control these factors. People in these studies were placed on medications, diet, and exercise, and were followed as their cholesterols were lowered. These studies showed a clear benefit in high-risk people. There was a further reduction in heart disease and heart disease death at LDLs of less than 70. And so what has been said is when it comes to LDL in a high-risk patient, the lower the better.

"These guidelines are not intended to take away from the importance of diet and exercise. What is known as TLC, or therapeutic lifestyle changes, are always endorsed in patients at high risk."

MODERATOR:
How long is it safe to be on a statin drug? Indefinitely?

NAZARIO:
That's a good question. Statins have not been around forever. We do have safety data on statin therapy for approximately 15 years to 18 years. This class of drugs has been studied intensely and in numerous amounts of people with various backgrounds, different sexes, and different ages.

So do we use them indefinitely? Our goal is to lower cardiovascular disease with these drugs, or the risk of cardiovascular disease with these drugs, which these drugs have had a very good track record of doing. But there are clearly some safety issues that most of us are concerned about. More recently, there have been concerns of certain statins and muscle problems, such as weakness, pain, and breakdown, which lead to potential kidney disease and the risk of death. These problems are not common and they are mainly reversible upon discontinuing these drugs.

These muscle problems are also seen in patients with other medical problems and seen in patients who combine drugs that affect how the statins are metabolized. These drugs and conditions include patients who have renal failure, patients who have hypothyroidism, and they're usually seen in the elderly over the age of 65, who, by the way, have multiple medical problems and take multiple drugs. They have been seen when statins are combined with another class of cholesterol-lowering medications, called fibrates. They're seen with certain antibiotics and antifungals.

I can only reiterate the recommendations and the cautions that should be given to patients on statins: If you have muscle pain or weakness, you must let your physician know. If you are taking a statin drug, your doctor should be aware of the other medications you are taking, in particular those that I've listed. Your doctor should, in all likelihood, do a blood test to determine what is going on with your muscle tissue.

MEMBER QUESTION:
What about someone who is at high risk, but also has liver function problems? Can they take statins?

NAZARIO:
As far as taking statins, there are side effects that relate to muscle breakdown and relate to problems in the liver. If you have active or chronic liver disease based on blood tests that your doctor can do, this is an absolute contraindication to the use of statin therapy. Before starting these drugs, it is recommended that your liver function test get done. During therapy, a follow-up of liver function tests are also done.

MODERATOR:
Did the recommendations change for HDL "good" cholesterol levels?

NAZARIO:
No. The recommendations did not change for HDL. The recommendations from the National Cholesterol Education Program are based on a primary target of LDL. What that means is your therapy is primarily driven by what your LDL is.

As far as increasing HDL, there appear to be insufficient trials to set a specific target goal for increasing HDL. So although we say, for example, a major factor for heart disease is a low HDL of below 40, and we say your HDL should be greater than 60, those recommendations have not changed and we're not changing the target, because we don't have at this time sufficient trials to set a specific goal.

There are lots of medications that can increase HDL and I think there was just really one big well-known trial that showed that increasing HDL decreased heart disease, but this was also in a specific group of patients who had low HDL and high triglycerides. These were patients that have diabetes and metabolic syndrome.

"In this country and in many parts of the world, as we see the increasing epidemic of obesity and diabetes, we are seeing atherosclerosis, or clogging of the arteries, even in young children."

MEMBER QUESTION:
Maybe a dumb question here: When you see pictures of clogged arteries, is that yellow material the actual cholesterol you're seeing, or does cholesterol cause that stuff to grow? And why does it accumulate near the heart? Why not in the legs or some place else?

NAZARIO:
That's actually a really good question. Cholesterol abnormalities and medical problems are not an easy topic. The yellow stuff you see in the images of the walls of arteries is plaque, and that is made up of cholesterol. There are also a lot of other substances there. There are, for example, cells that cause inflammation in there.

This process is not something that is exclusively seen on the arteries of the heart; it happens everywhere in the body. When it is on the heart arteries it is called coronary artery disease. Something called peripheral arterial disease is clogging of the arteries of the legs. Patients that have ministrokes tend to have clogged arteries in the major vessels leading to the brain. Those vessels are found in the neck. So when one talks about the process of clogging of the arteries, it's not a localized disease.

It is also not an age-specific disease. This is very, very important, because we tend to think of atherosclerosis and heart disease as a disease of someone who begins to age. In this country and in many parts of the world, as we see the increasing epidemic of obesity and diabetes, we are seeing atherosclerosis, or clogging of the arteries, even in young children. So this is not a disease or an area where we should hone in on preventative measures just on adults. Preventative measures need to be addressed in almost everyone.

MEMBER QUESTION:
My total cholesterol is 106, with an LDL of 41. I eat anything I want in any amount I want. Why does my level stay so low?

NAZARIO:
Although we don't have all the clinical information we need on you, it sounds like you're blessed with very good genes. Genes do play a very important role in the management of cholesterol and fats in the body. There are, on the other extreme, individuals who strictly follow a diet and still can't get their cholesterol into a near-normal range. Thank your parents for those genes.

MEMBER QUESTION:
Once someone reaches the proper blood cholesterol level do they need drugs to keep it that low? Is maintenance easier or harder than the actual lowering of the level?

NAZARIO:
I think that depends on the level at which you start. The higher your LDL cholesterol the riskier it is. In other words, the higher your risk of heart disease the more difficulty you will have in lowering that cholesterol. So an individual with a near-normal cholesterol level may just need diet alone, or exercise, whereas a person with a higher risk of heart disease, because of a higher LDL, may need not only therapeutic lifestyle changes, but they may also need a statin or a combination of a statin with one of the cholesterol-lowering drugs, such as a fibrate.

They may also need more intense dietary modifications. So although the diet that's typically recommended is one that has less than 7% of the calories coming from saturated fats. Someone who is following everything they need to do and still not attaining the target LDL may still need more intense dietary modification.

The benefits of statins extend beyond lowering LDL. So yes, to get back to your question, once you attain that goal typically patients are continued on statin therapy. In other words, independent of its effect in lowering your LDL, a statin can modify certain risks associated with heart disease. What I mean is I think we've all heard a little bit about the inflammatory marker called C-reactive protein. Statins not only lower LDL, they have been shown to lower this marker that has been linked to heart disease.

MEMBER QUESTION:
I have high cholesterol. What foods will help me lower it, and what causes it to be high? I am diabetic and have high blood pressure (under control).

NAZARIO:
Just the fact that you have diabetes puts you in a high-risk category. Your cholesterol should be less than 200 and your bad LDL cholesterol should be less than 100 because you're a high-risk patient. If you have also had a heart attack in the past, then you are considered a very high-risk patient, because you've already proven that your heart is diseased and you have an additional risk factor, which is the diabetes. If this is the case, your LDL should be less than 70.

Now let's look at the more general question of what foods increase your cholesterol, and in addition to that, what foods increase your triglycerides (which are typically high in a person with diabetes and have been linked with heart disease).

Normally, the body makes the majority of cholesterol. Cholesterol is needed to make various things the body needs and maintain the structural integrity of cells. We also get cholesterol from our diet. When we eat excess amounts of fat, and typically we get our fat from animal meats (at least in this country) and fried foods, we can increase our blood cholesterol, which gets deposited in the walls of the arteries of the body, a process called atherosclerosis. Triglycerides are typically elevated in the diabetic patient when he or she consumes too many carbohydrates, especially the simple carbohydrates.

In this case, a knowledgeable nutritionist should be part of the diabetic team treating you. I can only suggest looking at your diet, cutting back on meat, eating leaner types of meat, adding fish as a source of protein, and substituting potentially some of the simple carbohydrates, which you may consume for more complex whole grains. The other suggestion, which we all seem to forget, is adding fiber to our diet, about 25 grams a day.

Diet and exercise are the cornerstones of management for cholesterol abnormalities. In your case, this needs to go hand in hand with good management of your diabetes. I say this because based on the small bits of information that we have, you would be categorized as a high-risk patient, which means you need to work intensively to get your bad cholesterol levels less than 100 and potentially less than 70.

"These revised guidelines are one step closer to reaching a more accurate estimate of what a person's heart disease risks are."

MEMBER QUESTION:
What ever happened to the ratio 1-to-3, low-to-high, HDL-to-LDL?

NAZARIO:
That ratio is still used. It's the simplified calculation of what your risks are. As we continue to do studies on cholesterol and become more exact, we realize there are better ways to determine a person's true risk of heart disease. These revised guidelines, for example, are one step closer to reaching a more accurate estimate of what a person's heart disease risks are.

A very simple example is the idea of what LDL is. LDL at first was totally classified as bad cholesterol. As we progress in medicine and continue to do more research we realize LDL is more complex; there are some lighter, heavier, and denser molecules. The smaller, denser ones are the real dangerous ones. So now we can look at somebody's LDL and say OK, great, your cholesterol is right on target; it's less than 100, for example, but we can take that LDL and really break it up and look to see if this individual not only has attained the level of LDL we want them to, but whether they have the right LDL profile, which, by the way, statins do affect.

So basically, that ratio is something that's used but it's not quite as accurate as we used to believe.

MODERATOR:
Dr. Nazario, before we wrap things up, do you have any final words for us?

NAZARIO:
Thanks for having me. I hope we were able to convey the importance of getting your bad cholesterol under control. I hope we simplified the new revisions, but if you're still confused about the new revisions, don't worry; you can speak with your physician or look on our web site, where we've tried very hard to simplify these matters. Most of all, I hope I've been helpful. Thank you.

MODERATOR:
Thanks to Brunilda Nazario, MD, for sharing her expertise with us today.

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