Treatment of High Cholesterol

A new patient came to me after her father had suffered from a heart attack. Only after the heart attack did he find out he had hypercholesterolemia, or high cholesterol. Although my patient was a healthy 46-year-old woman, she also had high cholesterol, and she knew that hypercholesterolemia is a major risk factor for coronary artery disease (CAD)—the cause of heart attacks and angina. My patient's fasting lipid profile showed that she had a total cholesterol of 248 mg/ml, a low-density lipoprotein (LDL) of 162, a high-density lipoprotein (HDL) of 36, and a triglyceride level cholesterol of 250. She wanted to lower her cholesterol, but she had at least two other risk factors for CAD: she was post-menopausal and she smoked cigarettes.

Thus, in constructing a plan to reduce her cardiac risk, there was more to consider than just lowering her cholesterol down to a certain number. Let's look at the planning process in detail.

Assessing Cardiac Risk
A crucial part of the initial evaluation is assessing your risk factors for CAD, other than high cholesterol. The major risk factors are as follows:

  • Age older than 45 for men and 55 for women
  • Post-menopausal status (either natural or surgical) without hormone replacement therapy
  • Family history of early atherosclerotic heart disease (early meaning younger than the age of 55 for male relatives or younger than 65 for female relatives)
  • High blood pressure
  • Diabetes
  • Smoking
  • Low HDL cholesterol (less than 35 mg/dl)

Establishing a Treatment Goal
Your target cholesterol level depends on several factors. The first is whether or not you already have coronary artery disease. My patient, whom I described earlier, does not have angina or any other symptoms of heart disease, so we are treating her hypercholesterolemia for primary prevention of CAD. Her father has already had a heart attack, so lowering his cholesterol is very important for secondary prevention—i.e., for preventing a subsequent heart attack. Second, your treatment goal depends on your number of CAD risk factors, as detailed below. Unfortunately, diabetes is such a strong risk factor for CAD that it requires the same aggressive treatment as those who have established heart disease.

Table 1: Treatment goals recommended by the National Cholesterol Education Program and the American Diabetic Association

 LDL CholesterolTotal Cholesterol
No CAD and 0 or 1 risk factor (other than diabetes)< 160 mg/dl< 240 mg/dl
No CAD and 2 or more risk factors (other than diabetes) < 130 mg/dl < 200 mg/dl
Established CAD or diabetes < 100 mg/dl < 160 mg/dl

Dietary Therapy
For most people with hypercholesterolemia without heart disease, dietary therapy is initiated. The American Heart Association recommends the Step I diet, which limits fat and cholesterol intake. According to this diet, you should try to get 30 percent (or less) of your daily calories from fat, with no more than 10 percent of calories from saturated fat, and no more than 300 milligrams of cholesterol per day. The Step II and III diets limit your fat and cholesterol even more rigorously. What does this mean in practical terms? Let's talk about specific foods you can enjoy and foods you should limit or avoid.

Dietary Fats
First, let's look at dietary fats. There are three types, named for their basic chemical structure: saturated, polyunsaturated, and monounsaturated fats. Foods that are rich in saturated fat raise your cholesterol levels (particularly the "bad" cholesterol types) more than other foods. Examples of foods that are high in saturated fat include fatty cuts of red meat, whole-milk dairy products, pastries, butter, and coconut oil. These are foods you should try to avoid. Polyunsaturated fats are usually found in vegetable oils and fish. Monounsaturated fats are found in olive oil and canola oil, and are the most "heart-healthy" type of fat. Cholesterol is a component of all animal foods. Red meat, egg yolks, and whole milk are particularly high in cholesterol.

What are examples of heart-healthy foods? Thankfully, there are many. Whole-grain breads and cereals are a great source of fiber and are naturally low in fat. Fruits and vegetables, whether fresh, cooked, frozen, or canned, provide essential vitamins and minerals, and are also low in fat and calories. Low-fat or nonfat milk, yogurt, and cheese are important sources of bone-strengthening calcium. Fish and skinless chicken provide much-needed protein and contain less fat and cholesterol than red meat.

Table 2: Heart-healthy and not-so-healthy foods

Heart healthyNot heart healthy
Lean meat
Poultry without the skin (baked, grilled)
Fish (baked, broiled)
Fruits and vegetables
Whole grains, bread, cereal, pasta
Vegetable oil, olive oil
Skim or low-fat milk, low-fat yogurt, low-fat cheese
Egg whites
Sorbet, low-fat frozen yogurt
Fatty cuts of meat
Fried chicken
Fried fish
French fries, avocado
Croissants, pastry, doughnuts, cookies
Butter, mayonnaise
Whole milk, cream, cheese (except low-fat), cream cheese
Egg yolks
Ice cream

An easy way to figure out how much cholesterol you eat and what percentage of your calories comes from fat is to use the convenient nutrition labels on your food packages. The label will tell you the amount of cholesterol the food contains per serving, the total fat and saturated fat content, and the amount of calories per serving. It will also tell you the number and sometimes the percentage of calories derived from fat. Many foods are labeled low fat, fat free, or cholesterol free, and these are generally good choices; just remember that these foods may not be low in calories and may not be nutritious, so use your judgment.

Drug Therapy
Diet alone may not lower your cholesterol to your target level. In this case, your physician may prescribe a lipid-lowering medication.

The most widely-used class of lipid-lowering drugs are the statins: lovastatin, simvastatin, pravastatin, atorvastatin, etc. These drugs decrease the production of cholesterol in the body by inhibiting an enzyme and are the most effective drug for lowering LDL cholesterol. Treatment with a statin drug can lower the LDL cholesterol by 20 to 40 percent and triglycerides by 10 to 20 percent; it can also raise HDL cholesterol (the "good" cholesterol) by 5 to10 percent. The statins are generally very well tolerated. However, there are two potentially serious side effects: liver toxicity and myositis, (painful inflammation in the muscles), which are both reversible once the drug is discontinued.

The main reason that the statins are so popular is that they have been proven in many large, well-designed studies to decrease the risk of having and dying from a coronary event. Specifically, these drugs have been shown to decrease the need for angioplasty (a procedure wherein a small catheter with a balloon attached to it is introduced into a blocked coronary and inflated to open the blockage), bypass surgery, and hospitalization due to CAD; they also decrease the risk of having a heart attack and the risk of death from a heart attack or other manifestations of CAD.

Despite their wide use, statins are not for everybody. There are, however, other useful lipid-lowering drugs. Another commonly used and well-tolerated class of drugs are the fibric acid derivatives, such as gemfibrozil. These drugs can decrease triglyceride levels by 20 to 50 percent and increase HDL cholesterol by 10 to 20 percent; however, they are not effective in lowering LDL. Fibric acids are usually not combined with statins because their concurrent use increases the risk of developing myositis as a side effect.

Nicotinic acid (niacin) and bile acid sequestrants such as cholestyramine are two other types of lipid-lowering drugs, but these are often not well tolerated because of unpleasant gastrointestinal side effects like nausea and bloating.

If your physician starts you on lipid-lowering medication, you will need to stay on the medication long-term, provided you have no serious side effects. Your doctor will need to check your cholesterol profile periodically. Even once you attain your target cholesterol value, you should still continue to take your medication in order to maintain your cholesterol at a desirable level.

Lifestyle Modification
It is important to modify as many risk factors as you can in order to improve your overall cardiovascular health. This means quitting smoking, exercising regularly, losing weight, and keeping your blood pressure and blood sugar under control, if applicable. If you are post-menopausal, your physician may already have talked to you about starting estrogen replacement therapy for prevention of osteoporosis; earlier studies had suggested that estrogen replacement also helps prevent coronary artery disease, but this is still controversial.

So, how did my new patient do on her diet? She did rather well. After six months of following the Step I diet, her repeat level of total cholesterol was 236, LDL was 148, and her triglycerides were 240 mg/dl. However, she was still smoking and, in the interim, had been diagnosed with mild hypertension. I started her on a statin drug several weeks later, which she has tolerated well. She has managed to bring her LDL cholesterol down even lower to 140. Her target LDL is 130, so she is off to a great start.

Summary
Here are some additional, quick tips to help you lower your cholesterol. Good luck!

  • Eliminate high-fat, high cholesterol foods from your refrigerator and cabinets.
  • Substitute chicken, turkey, or fish for red meat.
  • Eat more fruits and vegetables.
  • Choose foods that are high in fiber, like whole grain bread and cereal.
  • Limit "fluff foods" like desserts or chips. If you can't resist, look for labels that say low fat or low cholesterol.
  • Try out some recipes from a low-fat cookbook.
  • If you're eating out, order a salad, either as your meal or before your meal. Share your entrée with a friend or take half of it home in a doggie bag.
  • Ask a friend to diet and exercise with you. You can be each other's moral support.
  • Take your medication at the same time every day. Keep the bottle where you can see it.
  • Keep your physician in the loop. Let him/her know if you're having progress, setbacks, or side effects.
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