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What is cholesterol?
How can LDL cholesterol levels be lowered?
What are the 2004 NCEP cholesterol treatment guidelines?
Why is HDL the good cholesterol?
What are triglycerides, chylomicrons, and VLDL?
What are lipid-altering medications?
What are the statin drugs?
What is nicotinic acid?
What are fibric acid derivatives (fibrates)?
What are bile acid sequestrants?
What is ezetimibe (Zetia)?
Is lowering LDL cholesterol enough?
What is lipoprotein (a), (Lp(a)) cholesterol?
Related cholesterol articles on WebMD:
Triglycerides
High cholesterol
Cholesterol levels
Related cholesterol article on eMedicineHealth:
High cholesterol
What is cholesterol ?
1
content, while foods of plant origin contain no cholesterol. After a meal,
cholesterol is absorbed by the intestines into the blood circulation and is then
packaged inside a protein coat. This cholesterol-protein coat complex is
called a chylomicron.
The liver is capable of removing cholesterol from the blood circulation as well
as manufacturing cholesterol and secreting cholesterol into the blood
circulation. After a meal, the liver removes chylomicrons from the blood
circulation. In between meals, the liver manufactures and secretes
cholesterol back into the blood circulation.
Total cholesterol is the sum of LDL (low density) cholesterol, HDL (high
density) cholesterol, VLDL (very low density) cholesterol, and IDL
(intermediate density) cholesterol.
2
The liver not only manufactures and secretes LDL cholesterol into the blood;
it also removes LDL cholesterol from the blood. A high number of active LDL
receptors on the liver surfaces is associated with the rapid removal of LDL
cholesterol from the blood and low blood LDL cholesterol levels. A deficiency
of LDL receptors is associated with high LDL cholesterol blood levels.
Both heredity and diet have a significant influence on a person's LDL, HDL
and total cholesterol levels. For example, familial hypercholesterolemia (FH)
is a common inherited disorder whose victims have a diminished number or
nonexistent LDL receptors on the surface of liver cells. People with this
disorder also tend to develop atherosclerosis and heart attacks during early
adulthood.
Diets that are high in saturated fats and cholesterol raise the levels of LDL
cholesterol in the blood. Fats are classified as saturated or unsaturated
(according to their chemical structure). Saturated fats are derived primarily
from meat and dairy products and can raise blood cholesterol levels. Some
vegetable oils made from coconut, palm, and cocoa are also high in saturated
fats.
3
Decreasing the risk of strokes. The same measures that retard
atherosclerosis in coronary arteries also benefit the carotid and
cerebral arteries (arteries that deliver blood to the brain).
Medications are prescribed when lifestyle changes cannot reduce the LDL
cholesterol to desired levels. The most effective and widely used medications
to lower LDL cholesterol are called statins. Most of the large controlled trials
that demonstrated the heart attack and stroke prevention benefits of
lowering LDL cholesterol used one of the statins. Other medications used in
lowering LDL cholesterol and in altering cholesterol profiles include nicotinic
acid (niacin), fibrates such as gemfibrozil (Lopid), resins such as
cholestyramine (Questran), and ezetimibe, Zetia. (An in-depth discussion of
these drugs is presented in this article starting at the heading: What are the
statin drugs?)
There are no established normal blood levels for total and LDL cholesterol.
In most other blood tests in medicine, normal ranges can be set by taking
measurements from large number of healthy subjects. For example, normal
fasting blood sugar levels can be established by performing blood tests
among healthy subjects without diabetes mellitus. If a patient's fasting blood
4
glucose falls within this normal range, he/she most likely does not have
diabetes mellitus, whereas if the patient's fasting blood sugar tests higher
than the normal range, he/she probably has diabetes mellitus and further
tests can be performed to confirm the diagnosis. Medications, such as insulin
or oral diabetes medications can be prescribed to lower abnormally high
blood sugar levels.
5
triglyceride levels and low HDL cholesterol levels). TLC Lifestyle
changes have the potential to reduce heart attack and stroke risks
through several mechanisms beyond the lowering of LDL cholesterol.
3. When LDL-lowering medication is used for very high, high or
moderately high risk patients, the report advises that the intensity of
LDL-lowering drug therapy be sufficient to achieve at least a 30 to 40
percent reduction in LDL cholesterol levels.
4. When a very high or high risk patient also has high blood triglyceride
or low HDL cholesterol levels, doctors may consider combining nicotinic
acid or a fibrate with a statin. Nicotinic acid and fibrates are more
effective than statins in lowering triglycerides and increasing HDL.
5. Age should not be a consideration since older persons also benefit
from lowering LDL cholesterol. Thus, it is never too late or the patient
too old to begin lifestyle changes and medications to lower LDL
cholesterol. A word of caution is in order. Elderly patients are more
likely to have liver and kidney dysfunction, and are also more likely to
be on multiple medications some of which may interfere with the
breakdown of cholesterol-lowering drugs such as statins. Thus lower
dosing may be necessary to avoid adverse side effects.
More intense
Risk Initiate TLC if Consider drugs +
LDL goal LDL goal
category LDL is: TLC if LDL is:
option
< 100
High risk > 100 mg/dl >100 mg/dl
mg/dl
Very high < 100
< 70 mg/dl > 100 mg/dl
risk mg/dl
Moderatel > 130 mg/dl >130mg/dl, consider
y high risk drug option if LDL is
(10 yr. 100-129 mg/dl
risk 10-
6
20%)
Moderate
risk (10
> 130 mg/dl >160 mg/dl
yr. risk
<10%)
>190 mg/dl, consider
Lower risk > 160 mg/dl drug optional if LDL is
160-189 mg/dl
High risk patients are those who already have coronary heart disease
(such as a prior heart attack), diabetes mellitus, abdominal aortic
aneurysm, or those who already have atherosclerosis of the arteries to
the brain and extremities (such as patients with strokes, TIA's (mini-
strokes), and peripheral vascular diseases). High risk patients also
include those with 2 or more risk factors (e.g., smoking, hypertension,
or a family history of early heart attacks) that places them at a greater
than 20 percent chance of having a heart attack within 10 years. (A
person's chance of having a heart attack can be calculated by using
the Framingham Heart Study Score Sheets, at
http://nhlbi.nih.gov/about/framingham/riskabs.htm).
Very high -risk patients are those who have coronary heart disease in
addition to having either multiple risk factors (especially diabetes), or
severe and poorly controlled risk factors (such as continued smoking),
or metabolic syndrome (a constellation of risk factors associated with
obesity, including high triglycerides and low HDL). Patients hospitalized
for acute coronary syndromes are also at very high risk.
Moderately high risk patients are those who have neither coronary
heart disease nor diabetes mellitus, but have multiple (2 or more) risk
factors for coronary heart disease that put them at a 10 to 20 percent
risk of heart attack within 10 years. (Use the Framingham Heart Study
Score Sheets, at http://nhlbi.nih.gov/about/framingham/riskabs,htm to
calculate the 10 year risk.)
7
Moderate risk patients are those who have neither CHD nor diabetes
mellitus, but have 2 or more risk factors for coronary heart disease
that put them at a
Lower risk patients are those with 0 to 1 risk factor for coronary
heart disease.
HDL is the good cholesterol because it protects the arteries from the
atherosclerosis process. HDL cholesterol extracts cholesterol particles from
the artery walls and transports them to the liver to be disposed through the
bile. It also interferes with the accumulation of LDL cholesterol particles in the
artery walls.
The risk of atherosclerosis and heart attacks in both men and is strongly
related to HDL cholesterol levels. Low levels of HDL cholesterol are linked to a
higher risk, whereas high HDL cholesterol levels are associated with a lower
risk.
Very low and very high HDL cholesterol levels can run in families. Families
with low HDL cholesterol levels have a higher incidence of heart attacks than
the general population, while families with high HDL cholesterol levels tend to
live longer with a lower frequency of heart attacks.
Like LDL cholesterol, life style factors and other conditions influence HDL
cholesterol levels. HDL cholesterol levels are lower in persons who smoke
cigarettes, eat a lot of sweets, are overweight and inactive, and in patients
with type II diabetes mellitus.
HDL cholesterol is higher in people who are lean, exercise regularly, and do
not smoke cigarettes. Estrogen increases a person's HDL cholesterol, which
explains why women generally have higher HDL levels than men do.
8
For individuals with low HDL cholesterol levels, a high total or LDL cholesterol
blood level further increases the incidence of atherosclerosis and heart
attacks. Therefore, the combination of high levels of total and LDL cholesterol
with low levels of HDL cholesterol is undesirable whereas the combination of
low levels of total and LDL cholesterol and high levels of HDL cholesterol is
favorable.
The total cholesterol to HDL cholesterol ratio (total chol/HDL) is a number that
is helpful in estimating the risk of developing atherosclerosis. The number is
obtained by dividing total cholesterol by HDL cholesterol. (High ratios indicate
a higher risk of heart attacks, whereas low ratios indicate a lower risk).
High total cholesterol and low HDL cholesterol increases the ratio and is
undesirable. Conversely, high HDL cholesterol and low total cholesterol
lowers the ratio and is desirable. An average ratio would be about 4.5.
Ideally, one should strive for ratios of 2 or 3 (less than 4).
In clinical trials involving lowering LDL cholesterol, scientists also studied the
effect of HDL cholesterol on atherosclerosis and heart attack rates. They
found that even small increases in HDL cholesterol could reduce the
frequency of heart attacks. For each 1 mg/dl increase in HDL cholesterol,
there is a 2 to 4% reduction in the risk of coronary heart disease. Although
there are no formal NCEP (please see discussion above) target treatment
levels of HDL cholesterol, an HDL level of
The first step in increasing HDL cholesterol levels (and decreasing LDL/HDL
ratios) is therapeutic life style changes. When these modifications are
insufficient, medications are used. In prescribing medications or medication
9
combinations, doctors have to take into account medication side effects as
well as the presence or absence of other abnormalities in cholesterol profiles.
The liver removes triglyceride and chylomicrons from the blood, and it
synthesizes and packages triglyceride into VLDL (very low-density
lipoprotein) particles and releases them back into the blood circulation.
10
Do high triglyceride levels cause atherosclerosis?
The first step in treating hypertriglyceridemia is a low fat diet with a limited
amount of sweets, regular aerobic exercise, loss of excess weight, reduction
11
of alcohol consumption, and stopping cigarette smoking. In patients with
diabetes mellitus, meticulous control of elevated blood glucose is also
important.
When medications are necessary, fibrates (such as Lopid), nicotinic acid, and
statin medications can be used. Lopid not only decreases triglyceride levels
but also increases HDL cholesterol levels and LDL cholesterol particle size.
Nicotinic acid lowers triglyceride levels, increases HDL cholesterol levels and
the size of LDL cholesterol particles, as well as lowers the levels of Lp (a)
cholesterol.
The statin drugs have been found effective in decreasing triglyceride as well
as LDL cholesterol levels and, to a lesser extent, in elevating HDL cholesterol
levels. A relatively new medicine, fenofibrate (Tricor), shows promise as an
effective agent in lowering serum triglyceride levels as well as raising HDL
levels, particularly in patients who have had suboptimal responses to Lopid.
In some patients, a combination of Lopid or Tricor with adjunctive statin
therapy (see below) may be prescribed. While this combination is often
effective in patients with complex lipid disorders, the potential for side effects
may be increased and such patients should be under strict medical
supervision.
12
lowering LDL cholesterol, others in lowering triglycerides, and some in
elevating HDL cholesterol. Medications also can be combined to more
aggressively lower LDL, as well as in lowering LDL and increasing HDL at the
same time.
The statins are the most widely used, and also the most powerful medications
13
for lowering LDL cholesterol. Numerous large, randomized, double-blind,
placebo-controlled, , clinical trials (controlled trials) have shown that statins
reduce heart attacks (and strokes) and improve survival. Statins are well
tolerated with low side effect rates when used long term. Statins not only
lower blood LDL cholesterol levels, they also modestly increase HDL
cholesterol levels and modestly decrease triglyceride levels. The statins that
are now on pharmacy shelves in the U.S. (putting the generic name first
followed by the brand name in parentheses) are:
rosuvastatin ( Crestor)
fluvastatin sodium (Lescol) made by Novartis
atorvastatin calcium (Lipitor) made by Parke-Davis and Pfizer
lovastatin (Mevacor) made by Merck
pravastatin sodium (Pravachol) made by Bristol-Myers Squibb
simvastatin (Zocor) made by Merck
Studies have consistently shown that lowering LDL cholesterol with diet and
statins reduces the risk of a second heart attack. The prevention of recurrent
heart attacks in patients who have already suffered a heart attack is called
secondary prevention.
Studies have also demonstrated that reducing LDL cholesterol with lifestyle
changes and statins reduces the risk of having the first heart attack.
Prevention of heart attacks in those who have never had a heart attack is
called primary prevention.
Studies have also confirmed that reducing LDL cholesterol benefits both men
and women, and the elderly. For more, please read our article on Statins.
14
How do doctors select statin drugs?
15
immediate release niacin, sustained release prescription brand Niaspan, and
over- the- counter (OTC) sustained release niacin. OTC preparations are not
federally regulated, and some OTC preparations may have no active
ingredient. Thus, they would be ineffective in either lowering LDL or raising
HDL cholesterol. Some formulations of OTC sustained release niacin have
been associated with liver toxicity and rare cases of fulminant (usually fatal
without liver transplantation) hepatitis have been reported. The prescription
brand sustained release Niaspan has been found in clinical trials to cause
only minor elevations in blood liver enzymes without causing significant liver
disease.
16
available in the United Sates include Gemfibrozil (Lopid) and fenofibrate
(Tricor).
Very high triglyceride levels (usually > 1000 mg/dl) can cause pancreatitis
(inflammation of the pancreas that can result in a serious an illness with
severe abdominal pain). By lowering the blood triglycerides, fibrates are used
to prevent pancreatitis.
Fibrates are not effective in lowering LDL cholesterol and cannot be used
alone in lowering LDL cholesterol levels. However, when a high risk patient
(see NCEP recommendations above) also has high blood triglyceride or low
HDL cholesterol levels, doctors may consider combining a fibrate, such as
fenofibrate (Tricor), with a statin. Such a combination will not only lower the
LDL cholesterol, but will also lower blood triglycerides and increase HDL
cholesterol levels.
Fibrates have also been used alone to prevent heart attacks especially in
patients with elevated blood triglycerides and low HDL cholesterol levels. In
one large study, gemfibrozil decreased the risk of heart attacks but did not
affect the overall survival of persons with high cholesterol levels. For more,
please read our article on Fibrates.
17
Bile acid sequestrants have modest LDL cholesterol-lowering effects. Low
doses (for example 8 gram/day of Cholestyramine) can lower LDL cholesterol
by 10%-15 %. But even high doses (24 gram/day of cholestyramine) can only
lower LDL cholesterol by approximately 25%. Therefore, bile acid
sequestrants used alone are not as effective as statins in lowering LDL
cholesterol.
However, bile acid sequestrants are most useful in combining with a statin or
niacin to aggressively lower LDL cholesterol levels. The statin-bile acid
sequestrant combination can lower LDL cholesterol levels by approximately
50%, lower than a statin alone. A statin-niacin combination can substantially
reduce LDL cholesterol and elevate HDL cholesterol. For more, please read
our article on Bile Acid Sequestrants.
Ezetimibe can be used alone or together with a statin drug. Ezetimibe used
alone is modestly effective in lowering LDL cholesterol. At a dose of 10
mg/day it can reduce LDL cholesterol by approximately 17%. When used with
a statin, it can reduce LDL cholesterol level further than a statin alone.
However, there is insufficient scientific data to determine whether a statin-
ezetimibe combination actually further reduces heart attack or stroke risks. A
new combination drug, Vytorin, is available and combines 10 mg of Zetia with
20, 40, or 80 mg of Zocor.
18
statin-ezetimibe combination may also be helpful in treating patients with
very high LDL cholesterol who cannot attain LDL cholesterol targets even with
maximal doses of statins. Ezetimibe can be taken with or without food and at
the same time as statin drugs.
19
Lipoprotein (a) (Lp(a)) is an LDL cholesterol particle that is attached to a
special protein called apo(a). In large part, a person's level of Lp(a) in the
blood is genetically inherited. Elevated levels of Lp(a) (higher than 20 mg/dl
to 30 mg/dl) in the blood are linked to a greater likelihood of atherosclerosis
and heart attacks in both men and women. The risk is even more significant if
the Lp(a) cholesterol elevation is accompanied by high LDL/HDL ratios.
20
***
I am sure many of you have been reminded by doctors, nurses, and public
health officials to lose excess weight, quit smoking cigarettes, exercise
regularly, and eat less saturated fat and sweets. Here is a real life example of
how effective these measures can be.
Last week, he asked his doctor for a complete blood panel that includes
cholesterol and triglyceride levels, since he has not had one for more than a
year. The nurse who drew his blood first noticed there was something wrong;
Mr. DT's serum was abnormally discolored. Before performing blood chemistry
measurements, she had to spin the blood sample in a centrifuge to separate
the red and white blood cells from the serum. Normal serum is clear yellow in
color. But Mr. DT's serum was pink and milky. Milky serum indicates excess
chylomicrons (protein complexes that contain high amounts of triglycerides
and cholesterol).
The laboratory reported the following morning that Mr. DT's cholesterol is
elevated at 260mg/dl, but more importantly his triglyceride level was 2,500
mg/dl! Normal triglyceride levels should be less than 150mg/dl. His good
cholesterol (HDL) is abnormally depressed at 20 mg/dl. These cholesterol and
21
triglyceride levels not only increased his risk of developing arteriosclerosis of
the arteries, the sky high triglycerides put him at risk of developing acute
pancreatitis---a painful, serious inflammation of the pancreas.
His doctor wasted no time in placing him on a strict low saturated fat and low
sweets diet, along with a medication that lowers triglycerides and increases
HDL. Over the weekend Mr. DT adhered faithfully to the prescribed diet and
the medication without cheating. Yes, he walked away from tiramisu,
chocolate cheesecake, mud pie, and fried calamari.
The doctor called Mr. DT into his office Monday morning for a repeat blood
test, only three days into treatment. This time, his cholesterol had dropped
down to 211 mg/dl, his HDL had risen to 44 mg/dl, and most impressively his
triglyceride level had dropped from 2,500 to 35 mg/dl.
1. Periodic blood lipid tests should be performed even when you feel fine.
2. Faithfully adhering to the diets prescribed by your doctor can make a
big difference. (Also don't forget that regular exercise, quitting
cigarettes, and losing and maintaining excess weight are also
important).
3. Do not despair if you have unfavorable cholesterol and triglyeride
numbers. Work diligently with you doctor to get them right!
***
22
High Cholesterol
23
everywhere in the body, including the brain, nerves, muscles, skin, liver,
intestines, and heart.
Your body uses cholesterol to produce many hormones, vitamin D, and the
bile acids that help to digest fat. It takes only a small amount of cholesterol in
the blood to meet these needs. If you have too much cholesterol in your
bloodstream, the excess may be deposited in arteries, including the coronary
(heart) arteries, where it contributes to the narrowing and blockages that
cause the signs and symptoms of heart disease.
A simple blood test checks for high cholesterol. Simply knowing your
total cholesterol level is not enough. A complete lipid profile measures
your LDL (low-density lipoprotein [the bad cholesterol]), total
cholesterol, HDL (high-density lipoprotein [the good cholesterol]), and
triglyceridesanother fatty substance in the blood. Government
guidelines say healthy adults should have this analysis every 5 years.
24
Updated cholesterol guidelines from the National Institutes of
Health (National Cholesterol Education Program) are
designed to help people become more aware of their
lipoprotein profile (that is your LDL, HDL, triglycerides, and
total cholesterol and their relationship to each other) and
perhaps to help at-risk people make lifestyle changes to
improve their profile.
A desirable total cholesterol level is 200 mg/dL or lower. A
desirable LDL is 100 mg/dL (130-159 is borderline high; 160
is high; 190 is very high). HDL, the "good cholesterol," should
be around 40 mg/dL or greater. With HDL, the higher the
number, the better, and 60 mg/dL is protective against heart
disease.
Too many Americans have high levels of total cholesterol and
LDL (the bad cholesterol). A diet high in saturated fat (a type
of fat found mostly in foods that come from animals and
certain oils) raises LDL levels more than anything else in your
diet. You also eat cholesterol in your diet, although the effect
of saturated fat in the diet is greater than the effect of
dietary cholesterol. Trans-fatty acids (seen in processed foods
and many "fast foods") can also increase LDL levels. Dietary
cholesterol is found only in foods from animal products.
Genetic factors combined with eating too much saturated fat
and cholesterol are the main reasons for high levels of
cholesterol that lead to heart attacks. Reducing the amount
of saturated fat and cholesterol you eat is an important step
in reducing your blood cholesterol levels. The government
has reset the standard for LDL levels so that more Americans
are included in the risk group.
Research confirms the dangers when your cholesterol levels are too
high.
25
The Framingham Heart Study established that high blood
cholesterol is a risk factor for coronary heart disease (CHD).
Results of the Framingham study showed that the higher your
cholesterol level, the greater your risk.
Several studies have confirmed a direct link between high
blood cholesterol and CHD. The Lipid Research Clinics-
Coronary Primary Prevention Trial (LRC-CPPT) first showed
that lowering total and LDL (bad) cholesterol levels
significantly reduces coronary heart disease. A series of more
recent trials of cholesterol-lowering using statin drugs have
conclusively demonstrated that lowering total cholesterol and
LDL cholesterol reduces your chance of having a heart
attack, needing bypass surgery or angioplasty, and dying of
CHD-related causes.
Recent studies have shown that lowering cholesterol in
people without heart disease greatly reduces their risk for
developing heart disease in the first place. This is true for
those with high cholesterol levels and for those with average
cholesterol levels.
In 1994, the Scandinavian Simvastatin Survival Study (4S)
was the first study to show that people who took the
cholesterol-lowering class of drugs called statins (in this case,
simvastatin) reduced their risk for major CHD events (such as
a heart attack) by 34%, CHD deaths by 42%, and all deaths
by 30% in people with known coronary heart disease and
high blood cholesterol levels, compared with people who
were given a placebo (a dummy pill that looks exactly like
the medication being tested). This has been called
"secondary prevention," or prevention of a second heart
attack, because the study involved people with known heart
disease, many of whom had already had at least one heart
attack.
26
A 1995 study called the West of Scotland Coronary
Prevention Study (WOSCOPS) found that lowering cholesterol
reduced the number of heart attacks and deaths from
cardiovascular causes in men with high blood cholesterol
levels who had not had a heart attack. For 5 years, more than
6,500 men with total cholesterol levels of 249-295 mg/dL
were given either a cholesterol-lowering drug or a placebo
along with a cholesterol-lowering diet. The drug that was
given is known as a statin (pravastatin), and it reduced total
cholesterol levels by 20% and LDL (bad) cholesterol levels by
26%. The study found that the overall risk of having a
nonfatal heart attack or dying from CHD was reduced by 31%
in those who received the statin. The need for bypass surgery
or angioplasty was reduced by 37%, and deaths from all
cardiovascular causes were reduced by 32%. A very
important finding was that deaths from causes other than
heart disease were not increased, and overall deaths from all
causes were reduced by 22%. This is called primary
prevention because the study subjects had not previously
had a heart attack.
In 1996, the CARE study of CHD patients with "normal"
cholesterol (LDL average of 138 mg/dL) values and a recent
heart attack was associated with 24% reduction in CHD
events. Overall death rates were not affected. The drug used
was pravastatin.
In 1998, the results of the Air Force/Texas Coronary
Atherosclerosis Prevention Study (AFCAPS/TexCAPS) showed
that lowering cholesterol in generally healthy men and
women (no previous heart disease) with average cholesterol
levels reduced their risk for a first-time major coronary event
(such as a heart attack) by 37%. Lovastatin was the drug
used in this study.
27
In the 1998 LIPID study, men and women with known
CHD and mild-to-moderate elevations of LDL lowered their
risk of death by 22%, CHD deaths by 24%, and death by CHD
or nonfatal heart attack by 24%. Pravastatin was the drug
used in this study.
The Heart Protection Study, published in 2002, examined
men and women of all ages at high risk for heart disease
irrespective of their cholesterol levels. Simvastatin treatment
reduced CHD events by 24%. This study has caused some
experts to suggest that everyone at high risk for CHD would
benefit from statin therapy, regardless of their blood
cholesterol levels.
The National Health and Nutrition Examination Survey III
(NHANES III), carried out from 1988-1991, discovered that
26% of American adults had high blood cholesterol
concentrations, and 49% had desirable values.
28
High Cholesterol Causes
Several drugs and diseases can bring about high cholesterol, but, for most
people, a high-fat diet and inherited risk factors may be the main causes.
Your doctor will rule out the possibility that you have an underactive thyroid
or kidney or liver disease.
Heredity: Your genes influence how high your LDL (bad) cholesterol is
by affecting how fast LDL is made and removed from the blood. One
specific form of inherited high cholesterol that affects 1 in 500 people
is called familial hypercholesterolemia, which often leads to early heart
disease. But even if you do not have a specific genetic form of high
cholesterol, genes play a role in influencing your LDL cholesterol level.
Age and sex: Before menopause, women usually have lower total
cholesterol levels than men of the same age. As women and men age,
their blood cholesterol levels rise until about 60-65 years of age. After
about age 50 years, women often have higher total cholesterol levels
than men of the same age.
Alcohol use: Moderate (1-2 drinks daily) alcohol intake increases HDL
(good) cholesterol but does not lower LDL (bad) cholesterol. Doctors
don't know for certain whether alcohol also reduces the risk of heart
disease. Drinking too much alcohol can damage the liver and heart
muscle, lead to high blood pressure, and raise triglyceride levels.
Because of the risks, alcoholic beverages should not be used as a way
to prevent heart disease.
29
Mental stress: Several studies have shown that stress raises blood
cholesterol levels over the long term. One way that stress may do this
is by affecting your habits. For example, when some people are under
stress, they console themselves by eating fatty foods. The saturated
fat and cholesterol in these foods contribute to higher levels of blood
cholesterol.
If you have a routine blood test during a physical exam or while attending a
health fair or screening at a shopping center, your blood may reveal a high
total cholesterol level, which would require further testing to determine your
LDL, HDL, and triglyceride levels (this is known as a lipid panel).
30
Low-density lipoprotein (LDL) is considered the "bad" cholesterol.
Cholesterol travels in the blood in packages called lipoproteins. Just like
oil and water, cholesterol, which is not soluble in water, and blood,
which is watery, do not mix. In order to be able to travel in the
bloodstream, the cholesterol made in the liver is combined with protein
and other substances, making a lipoprotein. This lipoprotein then
carries the cholesterol through the bloodstream. LDLs carry most of the
cholesterol in the blood, and the cholesterol from LDL is the main
source of damaging buildup and blockage in your arteries. Thus, the
more LDL cholesterol you have in your blood, the greater your risk of
heart disease. Reducing your LDL cholesterol is the main goal of
cholesterol-lowering treatment. The lower, the better.
31
Triglycerides are a form of fat carried through the bloodstream. Most
of your body's fat is in the form of triglycerides stored in fat tissue.
Only a small portion of your triglycerides is found in the bloodstream.
High blood triglyceride levels alone do not necessarily cause
atherosclerosis (the buildup of cholesterol and fat in the walls of
arteries). But some lipoproteins that are rich in triglycerides also
contain cholesterol, which causes atherosclerosis in some people with
high triglycerides; plus, high triglyceride levels are often accompanied
by other factors (such as low HDL and/or a tendency toward diabetes)
that raise heart disease risk. Therefore, high triglycerides may be a
sign of a lipoprotein problem that contributes to heart disease.
High cholesterol is just one of several risk factors for coronary heart disease.
Your doctor will consider your overall risk when assessing your cholesterol
levels and discussing your treatment options.
Risk factors are conditions that increase your risk for developing heart
disease. Some risk factors can be changed and others cannot. In general, the
more risk factors you have, the greater your chance of developing coronary
heart disease. You can control some risk factors, but you cannot control
others.
Age (45 years or older for men; 55 years or older for women)
Family history of early heart disease (father or brother
affected before age 55 years; mother or sister affected
before age 65 years)
32
Risk factors you can control
Self-Care at Home
If you have high lipoproteins and thus high cholesterol, your doctor will work
with you to target your levels with dietary and drug treatment. Depending on
your risk factors for heart disease, your target goals may differ for lowering
your LDL cholesterol.
33
Carbohydrates - 50-60% of calories
Medical Treatment
34
coronary heart disease risk factors (including high blood pressure, diabetes,
and smoking).
Taking all these steps together may lessen the amount of medicine you need
or make the medicine work better, which reduces your risk for developing
coronary heart disease. Your doctor may prescribe medication for you from
the following categories:
Statins: Statins lower LDL cholesterol levels more than other types of
drugs. Statins inhibit an enzyme, HMG-CoA reductase, that controls the
rate of cholesterol production in the body. These drugs lower
cholesterol by slowing down the production of cholesterol and by
increasing the liver's ability to remove the LDL cholesterol already in
the blood.
35
weeks, your doctor can do the first check of your LDL
cholesterol while you are on the medication. A second
measurement of your LDL cholesterol level must be averaged
with the first for your doctor to decide whether your dose of
medicine should be changed to help you meet your goal.
The statins are well tolerated, and serious side effects are
rare (liver problems, muscle soreness, pain, weakness). If this
happens, or if you have brown urine, contact your doctor
right away to get blood tests for possible muscle problems.
Rarely, widespread muscle breakdown, known as
rhabdomyolysis, can occur, usually in people who are taking
other drugs that interfere with the breakdown of the statin
and in people with advanced kidney problems. This is a
medical emergency. So, if you have diffuse muscle pain
and weakness, or brown urine (a possible sign of muscle
breakdown), contact your doctor immediately and stop taking
the statin medication. Some people experience an upset
stomach, gas, constipation, and abdominal pain or cramps.
These symptoms are usually mild to moderate and generally
go away as your body adjusts. Monitoring of liver function
tests is usually done in patients taking statins.
36
Lovastatin (Mevacor, Altocor): Lovastatin is the first
statin to be approved by the FDA. Lovastatin is proven
to reduce coronary heart disease events.
Pravastatin (Pravachol): Pravastatin is the most
studied statin in clinical trials and is also proven to
reduce coronary heart disease events and deaths.
Simvastatin (Zocor): Simvastatin is the first drug
shown to reduce the total death rate by reducing LDL
concentrations in people with coronary heart disease.
Simvastatin is proven to reduce coronary heart disease
events and deaths.
Rosuvastatin (Crestor): Rosuvastatin is the newest
statin (cholesterol-lowering drug) approved in the
United States and the most potent of the statin drugs.
It is particularly effective in lowering very high
cholesterol levels or when a cholesterol level has not
been decreased with other drugs.
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Bile acid sequestrant powders must be mixed with water or
fruit juice and must be taken once or twice (rarely, 3 times)
daily with meals. Tablets must be taken with large amounts of
fluids to avoid stomach and intestinal problems.
Sequestrant therapy may produce a variety of symptoms,
including constipation, bloating, nausea, and gas.
The bile acid sequestrants are not prescribed as the sole
medicine to lower your cholesterol if you have high
triglycerides or a history of severe constipation.
Although sequestrants are not absorbed, they may interfere
with the absorption of other medicines if taken at the same
time. You must take other medications at least 1 hour before
or 4-6 hours after the sequestrant. You should talk to your
doctor about the best time to take this medicine, especially if
you take other medications.
38
The immediate-release form of crystalline niacin is
inexpensive and widely accessible without a prescription,
but, because of potential side effects, it must not be used for
cholesterol lowering without the monitoring of a doctor.
(Nicotinamide, another form of niacin, does not lower
cholesterol levels and should not be used in place of nicotinic
acid.)
If you take nicotinic acid to lower cholesterol, your doctor will
closely monitor you to avoid complications from this
medication. You should not take this medication on your own.
You may miss important side effects.
Nicotinic acid reduces LDL cholesterol levels by 10-20%,
reduces triglycerides by 20-50%, and raises HDL cholesterol
by 15-35%.
A common and troublesome side effect of nicotinic acid is
flushing or hot flashes, which are the result of blood vessels
opening wide. Most people develop a tolerance to flushing,
which can sometimes be decreased by taking the drug during
or after meals or by the use of aspirin or other similar
medications prescribed by your doctor 30 minutes prior to
taking niacin. The extended-release form may cause less
flushing than the other forms.
The effect of high blood pressure medicines may also be
increased while you are on niacin. If you are taking high
blood pressure medication, it is important to set up a blood
pressure monitoring system while you are getting used to
your new niacin regimen. A variety of gastrointestinal
symptoms, including nausea, indigestion, gas, vomiting,
diarrhea, and the activation of peptic ulcers, has been seen
with the use of nicotinic acid. Three other major adverse
effects include liver problems, gout, and high blood sugar.
Risk of the latter 3 complications increases as the dose of
nicotinic acid is increased. Your doctor may not prescribe this
39
medicine for you if you have diabetes because of the effect
on your blood sugar.
Extended-release niacin is often better tolerated than
crystalline niacin. However, its liver toxicity (liver damage) is
probably greater. Therefore, the dose of extended-release
niacin is usually limited to 2 grams per day.
If you take niacin, you should increase the dose very slowly.
Recently, a combination product of extended-release niacin
(Niaspan) and lovastatin has been released (Advicor). The
side effects of this combination product mirror those of the 2
drugs taken individually.
40
women might have been treated with hormone replacement therapy
(replacing the estrogen and perhaps progestin).
Next Steps
Follow-up
Prevention
First, see your doctor. A simple blood test checks for high cholesterol.
You may be asked to fast overnight before the test. Just knowing your
total cholesterol level isn't enough. A complete lipid profile measures
your LDL, total cholesterol, HDL (the good cholesterol), and
41
triglycerides. The guidelines say healthy adults should have this
analysis every 5 years.
Next, set dietary goals based on the guidelines from the National
Cholesterol Education Program.
42
Fat-free or 1% milk
Cheese with 3 grams of fat or less per serving
Low-fat or nonfat yogurt
Lean cuts of meat - Eye of round beef, top round,
sirloin, or pork tenderloin
Lean or extra lean ground beef
Chicken or turkey - White or light meat, skin removed
Fish - Most white meat fish is very low in fat, saturated
fat, and cholesterol.
Tuna - Light meat canned in water
Peanut butter, reduced fat
Eggs, egg whites, egg substitutes
Low-fat cookies or angel food cake
Low-fat frozen yogurt, sorbet, sherbet
Popcorn without butter or oil, pretzels, baked tortilla
chips
Margarine - Soft, diet, tub, or liquid
Vegetable oil - Canola, olive, corn, peanut, or sunflower
Nonstick cooking spray
Sparkling water, tea, lemonade
Manage your cholesterol. You can take an important first step toward a
healthier heart by enrolling in the American Heart Association's
Cholesterol Low Down Program. High cholesterol is a leading risk factor
for coronary heart disease and stroke. Sign up by phone ([800] AHA-
USA1) or online at American Heart Association's Cholesterol Low Down
Program to receive life-management tools such as a newsletter, health
risk assessment, and healthy-living cookbooks and fitness tips.
Calculate your 10-year risk of having a heart attack. The risk
assessment tool presented at this link is from the National Heart, Lung,
and Blood Institute's National Cholesterol Education Program. It uses
scientific research information to predict your chance of having a heart
attack in the next 10 years. For adults older than 20 years who do not
43
have heart disease or diabetes, click the link to assess your risk score.
Those with diabetes and others with a 10-year risk greater than 20%
are considered to have the same risk for future heart disease events as
people with known coronary heart disease. You'll need to know your
total cholesterol, HDL cholesterol level, and systolic blood pressure (the
first number).
The National Cholesterol Education Program Web site will tell you what
your LDL cholesterol goal should be. For people with known coronary
heart disease and similar risk, the LDL cholesterol goal is less than 100
mg/dL.
Prevention
First, see your doctor. A simple blood test checks for high cholesterol.
You may be asked to fast overnight before the test. Just knowing your
total cholesterol level isn't enough. A complete lipid profile measures
your LDL, total cholesterol, HDL (the good cholesterol), and
triglycerides. The guidelines say healthy adults should have this
analysis every 5 years.
Next, set dietary goals based on the guidelines from the National
Cholesterol Education Program.
44
and sterols (included in certain margarines and salad dressings)
to boost your LDL-lowering power. The best way to know what's
in the foods you eat is to read the nutrition label.
Lower cholesterol levels start at the grocery store. Read food
labels, and buy foods low in saturated fat and low in cholesterol.
To help you know what to look for when grocery shopping, the
National Heart, Lung, and Blood Institute has a partial shopping
list for you.
45
Low-fat frozen yogurt, sorbet, sherbet
Popcorn without butter or oil, pretzels, baked tortilla
chips
Margarine - Soft, diet, tub, or liquid
Vegetable oil - Canola, olive, corn, peanut, or sunflower
Nonstick cooking spray
Sparkling water, tea, lemonade
Manage your cholesterol. You can take an important first step toward a
healthier heart by enrolling in the American Heart Association's
Cholesterol Low Down Program. High cholesterol is a leading risk factor
for coronary heart disease and stroke. Sign up by phone ([800] AHA-
USA1) or online at American Heart Association's Cholesterol Low Down
Program to receive life-management tools such as a newsletter, health
risk assessment, and healthy-living cookbooks and fitness tips.
Calculate your 10-year risk of having a heart attack. The risk
assessment tool presented at this link is from the National Heart, Lung,
and Blood Institute's National Cholesterol Education Program. It uses
scientific research information to predict your chance of having a heart
attack in the next 10 years. For adults older than 20 years who do not
have heart disease or diabetes, click the link to assess your risk score.
Those with diabetes and others with a 10-year risk greater than 20%
are considered to have the same risk for future heart disease events as
people with known coronary heart disease. You'll need to know your
total cholesterol, HDL cholesterol level, and systolic blood pressure (the
first number).
The National Cholesterol Education Program Web site will tell you what
your LDL cholesterol goal should be. For people with known coronary
heart disease and similar risk, the LDL cholesterol goal is less than 100
mg/dL.
46
Outlook
What Is Cholesterol?
47
How Are Cholesterol Levels Checked?
What the Numbers Mean
What Should I Do if I Have High Cholesterol?
What Is Cholesterol?
A simple blood test checks your cholesterol levels. This test measures total
cholesterol, low-density lipoproteins (LDL) cholesterol, high-density
lipoproteins (HDL) cholesterol, and triglycerides in your blood. Your doctor will
interpret your blood test results to determine if you have high cholesterol.
Total cholesterol is the sum of all the cholesterol in your blood. Your risk for
heart disease is greater with higher levels of total cholesterol. If your total
cholesterol level falls into the high-risk category, your risk of heart disease is
twice that of someone with the same risk factors, whose total cholesterol
level is 200 mg/dL or less.
Your total cholesterol will fall into 1 of 3 categories. However, the risk of
cardiovascular disease associated with these levels of cholesterol and
triglycerides will depend upon the presence or absence of other risk factors,
such as the presence of known cardiovascular disease (eg, prior heart attack
48
or stroke), hypertension, diabetes, cigarette smoking, age, sex, and positive
family history. Thus, cardiovascular risk and treatment options must be
considered in light of your overall cardiovascular risk profile.
Triglycerides are a form of fat carried through the bloodstream. A high level
of triglycerides may be a sign of a lipoprotein problem that contributes to
heart disease.
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Your triglyceride level will fall into 1 of 4 categories:
Because high levels of total cholesterol are associated with an increased risk
of heart disease, you and your doctor will discuss any treatment that may be
required based on your test results.
If you have high cholesterol, the main goal of a treatment program is to lower
your LDL cholesterol level. There are 2 main ways to lower your LDL
cholesterol level:
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You should also control any other risk factors that could affect your LDL
cholesterol and triglyceride levels, such as high blood pressure and diabetes.
You should quit cigarette smoking if you smoke.
51