Cholesterol’s at heart of matter
It’s a big factor in stroke and heart attack, but lifestyle changes cut risk
WHO’S AT RISK
Sixty percent of Americans will suffer a heart attack or stroke in their lifetime, and cholesterol plays a major role in many of these events.
“Cholesterol is a by-product of the animal fats found in meats, cheese and dairy products,” says Mount Sinai’s Dr. Jonathan L. Halperin. “The accumulation of cholesterol and plaque can narrow arteries, leading to atherosclerosis, the disease responsible for most cases of heart attack and stroke.”
In November, new cholesterol guidelines were released by the National Institutes of Health, the American Heart Association and the American College of Cardiology.
“For years, we told patients, ‘Know your numbers,’ and told doctors under certain conditions to ‘treat the numbers,’ to push the ‘bad cholesterol’ — LDL cholesterol — below 100 or even below 70 mg/dl,” says Halperin. “Upon carefully reviewing the literature, however, we found that aiming at a particular LDL goal was not the strategy that was proven effective. Instead, we recommend guiding treatment according to a patient’s cardiovascular risk, which is affected by other factors in addition to the cholesterol level.”
Halperin says: “Along with high cholesterol, the primary risk factors for cardiovascular disease are high blood pressure, smoking, being overweight or living a sedentary lifestyle — and these are all modifiable risk factors.
“The other important risk factor is genetics — a family history of the disease — but since there’s nothing you can do about that, we focus on the modifiable factors.”
No one is exempt from the risk of cardiovascular disease. “Men and women are both at risk, and while there are different rates of risk in different racial groups, no group is fully protected,” says Halperin. “Similarly, while risk goes up with age, we see people in their 90s whose arteries are spick-andspan, while in others atherosclerosis begins in childhood.”
SIGNS AND SYMPTOMS
The vast majority of patients learn of high cholesterol as the result of a blood test. “There are usually no symptoms early in the disease and that’s the reason prevention is so important,” says Halperin. “However, a minority of patients do have visible signs like yellow streaks around the eyes, or lumps on the tendons of the arms and legs. Risk goes beyond the cholesterol levels gathered through blood tests, and everyone needs a fuller picture of his or her cardiovascular risk.”
l TRADITIONAL TREATMENT
The combination of lifestyle changes and medications can go a long way to cutting cardiovascular risk. “There’s a great deal that a patient can do, like quitting smoking, keeping weight under control, exercising, eating a healthy diet, and controlling high blood pressure and diabetes,” says Halperin. “You might not be able to pick your parents, but a heart-healthy lifestyle is the foundation of cardiovascular disease prevention.”
Doctors have effective medications to lower LDL cholesterol, but medicines that raise the good cholesterol (HDL) are less dependable. “Statin drugs are among the most widely prescribed drugs in the world — brands like Lipitor, Zocor and Crestor — because they are extremely effective,” says Halperin. “What we are coming to appreciate is that these drugs also lower cardiovascular risk by doing other things that we can’t currently measure, perhaps by reducing inflammation or having other effects on the arterial walls.”
The new guidelines clarify that some patients with low blood cholesterol levels may benefit from statin therapy if they have other risk factors for cardiovascular disease. “For instance, patients who have already had a heart attack or stroke might have normal or low LDL cholesterol levels, but studies have found that these patients benefit from statins — these drugs still lower their risk of future heart attack and stroke,” says Halperin. “The combined package of risk matters more than any single number.”
Taken together, the results of many studies show that people whose risk of heart attack or stroke in the next 10 years is higher than 7.5% should probably take a statin.
When statins alone aren’t enough, there are more aggressive treatments. “Once plaque has narrowed arteries more severely, there are minimally invasive procedures like angioplasty or stenting that open narrowed arteries,” says Halperin. “And for patients with more advanced disease, there is bypass surgery. Every step of the way, there’s so much we can do to protect or improve cardiovascular health.”
RESEARCH BREAKTHROUGHS
Development of new drugs and treatment approaches is underway. “Investigators are working on new agents to lower cardiovascular risk, both in addition to statins and for people who can’t tolerate statins,” says Halperin. “We’re moving away from the old model of focusing on the numbers, to reducing a person’s overall risk.”
QUESTIONS FOR YOUR DOCTOR
Since plaque buildup can start as early as childhood, just about anyone can benefit from asking, “Do I have evidence of atherosclerosis?” and “Is there anything I can do to reduce my risk?” Because many aspects of the disease are inherited, patients diagnosed with any form of heart disease should ask, “Is there anything the members of my family should do to reduce their risk?”
“If you’re discouraged by your cardiovascular history, don’t feel cursed. It’s amenable to preventive strategies at almost every stage of the disease,” says Halperin. “Be optimistic, because there’s a great deal that we can do for almost every patient to improve their heart health.”