It's no longer as simple as seeing how the numbers stack up. New recommendations for managing blood cholesterol are steering high-risk patients and their doctors toward a more personalized approach.
In those at heightened risk of heart attack and stroke, the target has shifted away from lowering just the LDL cholesterol (known as the “bad” cholesterol) level. Now, the goal is optimizing treatment based on each individual's risk. For some, a higher dose of statins—the main cholesterol-lowering drugs—may be needed, while for others, dietary and lifestyle changes may be enough.
The new guidelines were published last November by the American Heart Association and the American College of Cardiology. They aim to prevent hardening and narrowing of the arteries, or atherosclerosis. This occurs when plaques build up from fat, cholesterol and calcium in the blood, eventually blocking the arteries that pump blood from the heart to the body.
Cholesterol in your body
Cholesterol travels through the bloodstream in small packages called lipoproteins. Two major types of lipoproteins transport cholesterol throughout the body:
- Low-density lipoproteins (LDL). LDL cholesterol sometimes is referred to as “bad” cholesterol because it carries the waxy, fat-like substance to tissues, including your heart's arteries.
- High-density lipoproteins (HDL). HDL cholesterol sometimes is called “good” cholesterol because it helps remove cholesterol from your arteries.
Every four to six years, adults age 20 to 79 should have a fasting lipoprotein profile, which measures total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides. This test is performed after a 9- to 12-hour fast. The results will show your cholesterol levels in milligrams per deciliter of blood (mg/dL). To evaluate the impact of these cholesterol levels on your risk of cardiovascular disease, your doctor also will consider other risk factors, such as your age, family history, smoking and high blood pressure.
Lifestyle changes continue to be the most important part of reducing the risk of atherosclerosis, the panel of experts stated in the guidelines. This means sticking with a heart-healthy diet, committing to regular physical activity, avoiding tobacco products and maintaining a healthy weight. This is important whether you're taking statins or not.
At a time when cardiovascular disease remains the leading cause of death and a leading cause of disability in the United States, the panel identified four major groups of patients for whom statins have the best chance of helping prevent heart attacks and strokes. These are patients with:
- a previous heart attack or stroke
- an LDL cholesterol level of 190 mg/dL or higher
- diabetes, aged 40 to 79 years, with an LDL cholesterol level of 70 to 189 mg/dL
- a 10-year estimated heart attack and stroke risk of 7.5 percent or higher, with an LDL cholesterol level of 70 to 189 mg/dL (your doctor can help you determine your heart attack and stroke risk).
Your doctor will work with you to understand your risk and then recommend the most suitable approach, including the advantages and disadvantages of treatment with statins. Ultimately, the goal is for more people to manage their cholesterol with the appropriate therapy, says cardiologist Neil Stone, M.D., M.A.C.P., F.A.H.A., F.A.C.C., a professor at Northwestern University's Feinberg School of Medicine in Chicago and chair of the expert panel.
“This is to be sure statin treatment makes sense, after reviewing the potential for benefit as well as the potential for adverse effects and drug-drug interactions,” he says. “Importantly, this discussion is the perfect place to stress optimal lifestyle, taking care of other important risk factors and the patient's preferences.”
The panel listed criteria to help doctors determine whether a patient requires a statin to reduce his or her risk for heart attack or stroke. Factors to consider with your doctor include a family history of premature heart attack or stroke and an LDL cholesterol level of 160 mg/dL or higher. Your doctor may also suggest a high sensitivity C reactive protein inflammation test or a coronary artery calcium score, which can help determine your risk.
The panel focused on statins because they have been found to be the most effective medicines to reduce cholesterol. New scientific evidence continues to surface about how to best prevent and treat diseases of the heart and blood vessels. The most solid evidence emerges from randomized clinical trials, which follow rigorous standards to collect and analyze data. The new cholesterol management guidelines place a premium on such data, says William P. Fay, M.D., a professor and director of the Cardiovascular Medicine Division at the University of Missouri at Columbia.
“The new guidelines emphasize global risk assessment, not just blood cholesterol levels, in selecting individuals who are likely to benefit from statin therapy,” says Fay, who wasn't part of the expert panel drafting the document. “Other components of ‘global risk’ include age, gender, diabetes, high blood pressure and cigarette smoking.”
It is important to take these factors into account when deciding whether or not to start a patient on a statin. “Some individuals with normal or near-normal cholesterol levels should be considered for statin therapy,” Fay says, “if the other parameters of their global risk assessment identify them to be at high future risk of heart attack or stroke.”
There is a small, but significant, possibility that statins and other cholesterol-lowering drugs, such as niacin, could cause problematic side effects, Fay says. Some patients may require more careful monitoring, while others may need to completely avoid statins.
The most common side effect from taking a statin is muscle pain or weakness. Based on your symptoms or lab test results, your doctor can refer to the guidelines for specific advice on how to manage your side effects.
Summarizing the new recommendations, Jarett Berry, M.D., F.A.H.A., a cardiologist at the University of Texas Southwestern Medical Center in Dallas, says, “These changes occurred because of the weight of evidence that has accumulated over the past few years, suggesting that benefit from statin therapy was largely independent of LDL cholesterol level. In fact, the data suggest that the benefit of statins is better predicted by overall cardiovascular risk than by LDL cholesterol level.”
DAY-TO-DAY CHOICES MATTER
A healthy diet and exercise are vital to fend off high cholesterol and heart disease. Risk reduction begins with knowing your lifestyle habits.
Know your numbers, but treat your risk
A constellation of “numbers” is used to determine one's personal risk of heart attack and stroke. The American Heart Association recommends that everyone know where they stand with the following four measurements. Ideal numbers for most adults are:
- Total cholesterol of less than 180 mg/dL
- Body mass index (BMI) of less than 25 kg/m2
- Blood pressure of less than 120/80 mm/Hg
- Fasting blood sugar of less than 100 mg/dL
High cholesterol may cause serious heart disease to develop. It's important to have your cholesterol levels monitored because, in most cases, high cholesterol doesn't have any symptoms.
Ask your doctor if you're at risk for a heart attack and stroke. If so, what's the best prevention strategy? And if you're not at risk now, what can you do to avoid becoming at risk?
The new guidelines for managing cholesterol represent a real change—for the better, says Clyde W. Yancy, M.D., M.S.C, F.A.C.C., F.A.H.A., M.A.C.P., cardiology division chief at Northwestern University's Feinberg School of Medicine and associate director of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital in Chicago.
“There is less emphasis on a target and a greater emphasis on the patient,” Yancy says. “We should treat those whom we know will benefit most from currently available therapies. We've also made it much easier for providers and patients to better understand risk; we are not all the same nor is our risk for heart disease or stroke the same.”
As the youngest baby boomers (those born in 1964) mark their milestone 50th birthdays this year, a large segment of the population also enters the target zone for heart disease and stroke, Yancy says.
“Now is the time to adopt, incorporate and follow heart-healthy adjustments in lifestyle and heart-healthy diets,” he says. “The secret weapon here? Weight control. We believe in several simple guiding principles—do more, eat less, know your numbers. And we especially endorse the AHA's ‘Life's Simple 7.’ Our view is that lifestyle change and reduction in the risk for heart disease are now well within hand for all of us.”
Life's Simple 7 refers to the seven-step list designed to promote a long, productive healthy life (for more information, visit heart.org/mylifecheck). Even modest improvements will make a big difference. Start with one or two of these seven measures: get active, eat better, lose weight, stop smoking, control cholesterol, manage blood pressure and reduce blood sugar.
More specifically, Yancy offers the following tips to stay healthy:
- Avoid big changes. They're just not sustainable. A “biggest loser” mentality is not the norm in weight loss. It's better to shed one to three pounds per month. In one year, you would shave off a total of 12 to 36 pounds.
- Don't go at it alone. Team up with your spouse, significant other, friend, neighbor or a support group.
- Keep it simple. Try walking for a great form of physical activity. Enjoy apples as a nutritious snack. If you smoke, stop—for good.
“We've made tremendous strides in our treatment of heart disease, and we've seen real progress,” Yancy says, citing a 50 percent reduction in deaths from coronary heart disease since 1975. This represents the most significant decline in any disease during that time frame, with 35 percent of the decrease occurring since 2000.
“Prevention remains a much better option than any therapy,” he concludes. “It's a lot cheaper, and you can't help but feel better with the positive feedback from weight loss, increased energy and a renewed outlook on life.”
What to eat and what not to eat
Small changes can go a long way toward controlling your cholesterol. You are much more likely to succeed with sustainable modifications that are compatible with your food preferences and lifestyle rather than making a drastic redesign of your diet.
- Decrease portion sizes of meat. A 3- or 4-ounce portion is sometimes referred to as the size of a deck of cards. Choose lean cuts and remove skin from poultry before eating.
- Steer clear of artery-clogging fats such as butter, cream, palm oil, palm kernel oil, full-fat dairy products (ice cream and whole milk), too many commercial baked goods and fried foods. Shift to low-fat or non-fat dairy products.
- Avoid hydrogenated or partially hydrogenated oils in products from the grocery store. Both are an indication that an item contains trans fats. When it comes to fat, some doctors consider trans fat—also called trans-fatty acids—to be the worst type of fat. Unlike other fats, trans fat raises your LDL cholesterol and lowers your HDL cholesterol.
- Experiment with drizzling olive oil vinaigrette on your salad instead of another dressing. Olive oil has been shown to reduce LDL cholesterol.
- While you're making changes to your diet, don't forget to get moving. Find a form of physical activity that you enjoy and can maintain for the long term.
Sources: Ximena Jimenez, M.S., R.D.N., L.D., registered dietitian and national spokesperson for the Academy of Nutrition and Dietetics (formerly known as the American Dietetic Association); and Alice H. Lichtenstein, D.Sc., senior scientist and director of Tufts University's Cardiovascular Nutrition Laboratory and Tufts' Jean Mayer USDA Human Nutrition Research Center on Aging in Boston. Lichtenstein served as vice chair of the expert panel that wrote the new cholesterol guidelines.