Cholesterol.  I attended a lecture recently from a well-known local cardiologist specializing in cholesterol.  Here are the “pearls” from the talk.

What is cholesterol?  Cholesterol are lipids that are carried on particles.  A cholesterol panel estimates what kinds of particles are circulating in a patient’s blood, as cholesterol can be small or large or dense.  Hint: you would like your cholesterol large and buoyant.

The LDL is the bad cholesterol that is found in a plaque.  Plaque is what accumulates on the walls of the blood vessel that decreases the blood able to flow through that blood vessel.  VLDL are triglyceride-rich particles that are also found in plaque.

The LPLa (lipoprotein a) is a good thing, it’s a molecule that helps to break down cholesterol.  LPLa is down-regulated (this is bad) in obese patients.

LDL-c is the concentration of LDL.  A Direct LDLc can be asked for at the lab.  A lipid panel is meant to tell us physicians, what are the chances that you have atherosclerosis which is what leads to an athlerosclerotic cardiovascular disease event (ASCVD).

What can we do? First, we treat cardiovascular risk!

• Lifestyle modification is first line therapy: decrease saturated fats, increase dietary intake of fats from fish, increased dietary and supplemental fiber, increase soy protein, increase nuts, weight loss, exercise.
• Use the risk calculator.  There are separate treatment pathways for primary and secondary prevention.
• “Risk enhancers” should be considered… including coronary calcium scores.
• Emphasize rechecking lipids after starting therapy.
• Consider non-statin therapies like ezetimibe and psck9i-medications.

How to decrease triglycerides?

• consume  low carbohydrate and low sugar diet.
• Avoid excess fat in diet.
• Add omega-3 supplements.

How to raise HDL?

• Exercise.
• Stop smoking.
• Moderate alcohol intake (1-2 glasses of red wine/day).

When to start a statin?

1. Known ASCVD (atherosclerotic cardiovascular disease).  This is a patient with known vascular disease, a history of stroke or heart attack or peripheral vascular disease.
2. LDL more than 190, in a patient more than 21 years old.
3. In a patient without an ASCVD event, but has diabetes, is aged 40-75, and has an LDL between 70-190.
4. In a patient with an ASCVD-event risk of 7.5% in 10 years or more.
   1. Want to know your ASCVD risk score? http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/

Who should get a coronary calcium score?

• If a patient is resistant to starting on a statin despite the labs showing that statins are suggested, a coronary calcium score is a test that can give us more information.  If the coronary calcium score is zero, then the chance of a ASCVD risk in the next 10years is low, so maybe no statin is needed.

Do statins help?  Yes!

• It is know that statins help decrease ASCVD events by 30-60%!  That is fantastic!

What are the drawbacks?

• 5-10% of patients complain of muscle pain.
• It may lead to new-onset diabetes, but most of these patients are already at risk for diabetes (risk factors for diabetes are a BMI of more than 30, fasting blood sugar is already more than 100 or in a patient with hemoglobin A1c of more than 6%).