National Cholesterol Education Month – check your cholesterol levels

couple bike riding

Today September – National Cholesterol Education Month – comes to a close.

Two weeks ago I participated in the First International Familial Hypercholesterolemia (FH) Summit, hosted by the FH Foundation and attended by 120 cholesterol experts from around the world. It was an inspiring event. Katherine Wilemon, a young heart attack survivor and bearer of the not-so-uncommon and far-too-frequently deadly genetic cholesterol disorder FH, led the charge for FH awareness and concomitant therapy. We all left the meeting brimming with optimism.

Last week I had the privilege of delivering Grand Rounds at UCI, again on the subject of FH. The message was well received; if doctors fail to consider FH we will of course fail to identify it. Absent its identification, treatment cannot be rendered. Translation – we must put FH on our radar screen.

While many of us are working tirelessly to “spread the word”, naysayers blather uncensored on the internet and in the popular press about the dangers of cholesterol lowering drugs and the fallacy of the “cholesterol hypothesis”. Never before has medical science so clearly identified a culprit for heart disease and never before have we had such wonderful ways to mitigate the threat. Yet the gains we make are eroded daily by these adversaries. What are we to do? Somehow less knowledgeable but more vociferous folks have usurped our podium. Somehow the public has lost faith in medical science, instead choosing to believe oftentimes fork-tongued purveyors of “anti-science” spreading the paranoid perspective that drug companies and doctors conspire solely for their own advancement. How do we fight and win this battle? I believe that victory rests in patients once again understanding why it is that doctors deliberately choose their arduous path. Doctors don’t whimsically decide to devote ten or more years of their post-college lives to incomparably hard work and abysmal pay. The decision to become a physician is always well-considered. It is also a choice that can be made by only the brightest and hardest working young men and women. So what is the common denominator that drives these people to enter an exhausting and oftentimes unappreciated profession? Simply put, it is to help others. Doctors become doctors because they care. This I can promise you to be true. So when your doctor offers advice about cholesterol (or other issues for that matter) please consider from whence the advice originates. Contrast that to the recommendations you may see or hear on the internet, through the media, or even from an ostensibly well-meaning friend.  Doctors have their patients’ best interests at heart. The same is not so clear about the naysayers.

So at the close of National Cholesterol Education Month, do yourself and your loved ones a favor. Check your cholesterol levels. Then speak with your doctor. Be sure you’re being treated as well as we can treat you. It really could save your life.

Learn more about comprehensive preventive cardiology at preventivecardiologyinc.com

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Cholesterol and Vascular Disease Part 6: LDL-Apheresis and Other Novel Cholesterol Strategies

September is National Cholesterol Education Month. In support of this important educational initiative we are republishing our six part series on cholesterol and the role it plays in cardiovascular disease.

Note: Seventy-one million American adults have high cholesterol, but it is estimated that only one-third of them have the condition under control.

Today’s final post in my six-part series on cholesterol examines one FDA approved non-medication treatment for severely elevated LDL cholesterol, and three novel medications on the horizon.

LDL-Apheresis is a non-drug therapy for patients with vascular disease and LDL-C > 200. It is reserved for patients with a genetic disorder called Familial Hypercholesterolemia (FH), or those individuals who cannot tolerate standard medications but still have very high LDL levels. Therefore, this treatment is clearly not for everyone. In a manner similar to dialysis, patients are connected to a filtering machine through two IV lines. Blood is withdrawn from one arm, circulated through a series of filters and returned to the body through the other arm. Typically the procedure is performed every other week. Each treatment results in a 60% to 80% reduction in LDL particles. After treatments, the LDL will rise steadily until it can be lowered once again with another therapy. Although LDLs do increase after a treatment, studies have demonstrated a nearly 75% reduction in cardiovascular events when patients are treated with LDL-Apheresis. Thus, LDL-Apheresis is a viable option for high risk patients. I am very fortunate to be able to run one of the forty or so centers in the USA, and I am happy to say that not only is the procedure extraordinarily well tolerated, but also the lipid effects are nothing short of remarkable.

As for the medications on the horizon, three deserve immediate recognition: Mipomersen, Lomitapide, and REGN727. These are all currently “experimental” but deserve mention not just because they will likely soon be on the market, but because each one represents a truly fresh way to lower LDL.

  • Mipomersen, licensed by Genzyme, is a second generation antisense oligonucleotide that is administered weekly by injection. It dramatically lowers LDL. The English translation is that this drug thwarts our body’s LDL production mechanism at the DNA level. DNA’s job is to produce mRNA in order to translate DNA’s protein-producing knowledge into the actual creation of proteins. Mipomerson binds and inactivates the mRNA that carries the code for the essential protein in every LDL particle, apoB. Without apoB, LDL cannot be created. Mipomerson does not block cholesterol production; it stops our body from producing too many LDL particles. Very different from the way statins work! Read More…

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Cholesterol and Vascular Disease Part 5: Non-Statin Cholesterol Medications

September is National Cholesterol Education Month. In support of this important educational initiative we are republishing our six part series on cholesterol and the role it plays in cardiovascular disease.

Note: Seventy-one million American adults have high cholesterol, but it is estimated that only one-third of them have the condition under control.

Previously, in Part 4 of this blog series on cholesterol we spoke about the statins. This week we will look at other cholesterol medications. Another very effective method for decreasing LDL is by combining a statin with other drugs.

Medications

  • One of the most effective add-on medications is Ezetimibe. This medicine works by blocking cholesterol absorption in our small intestine. It’s not just the cholesterol we eat that is blocked; more importantly it’s the enormous amount of cholesterol that is recycled daily between our liver and intestine. At this point, clinical trials have failed to demonstrate a reduction in heart attack and stroke by using Ezetimibe. Still, many lipid specialists (me included) believe that future trials will demonstrate its importance in particular patient populations.
  • Another important class of cholesterol-lowering drug is called the bile acid sequestrants. Welchol is the most commonly utilized of these medications. By blocking the reabsorption of bile acids in our intestine our liver is forced to produce more bile acids from their precursor, cholesterol. Interestingly, WelChol also has the added benefit of lowering blood sugar and increasing HDL. Patients with very high triglycerides should be careful of this medication because it can increase triglycerides further. Like Ezetimibe, WelChol is best used in combination with a statin. Read More…

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Cholesterol and Vascular Disease Part 4: The Great Statin Debate

September is National Cholesterol Education Month. In support of this important educational initiative we are republishing our six part series on cholesterol and the role it plays in cardiovascular disease.

Note: Seventy-one million American adults have high cholesterol, but it is estimated that only one-third of them have the condition under control.

It has been unequivocally established that high levels of LDL can lead to heart attacks and strokes. Parts 1- 3 of this blog described the history of cholesterol, the superiority of LDL particles over LDL cholesterol, and the pathophysiology associated with an overabundance of LDL particles. In addition to our understanding of the biological process whereby LDL particles cause vascular disease, we also have a plethora of clinical trials demonstrating the efficacy of lowering LDL.

Everyone–lay people, physicians, and scientists–is plagued by the overabundance of clinical trials involving all aspects of health and medicine, many of which clearly contradict one another. In order to practice medicine in a fashion that appropriately considers the outcomes of these clinical trials, one must find a way to make sense of them. My approach has been to evaluate the clinical trials not just individually, but as a whole. I look for trends. When studies repeatedly reach the same conclusions (especially when they pathophysiologically “make sense”) I feel much more comfortable concluding that they are correct. In the case of LDL we find a commonality that is indisputable. The studies repeatedly demonstrate that statins–a class of cholesterol lowering medications I will momentarily describe–uniformly decrease the risk of cardiovascular events by about 30%. This event reduction is consistent among patients in the setting of both primary and secondary prevention. And so we must listen to the studies and lower our patients’ LDLs accordingly.

Statins are the class of medication for cholesterol management that unequivocally possess the greatest amount of science supporting their use. These medications work by blocking a critical enzyme in our body’s production of cholesterol. In response to lower levels of cholesterol within our cells, the cells increase surface receptors to bring in more LDL particles. The result is a diminution in the number of LDL particles – as well as the LDL cholesterol – in our bloodstream. Read More…

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Cholesterol and Vascular Disease Part 3: How Tiny LDL Particles Can Cause Such Harm

September is National Cholesterol Education Month. In support of this important educational initiative we are republishing our six part series on cholesterol and the role it plays in cardiovascular disease.

Note: Seventy-one million American adults have high cholesterol, but it is estimated that only one-third of them have the condition under control.

Previously we discussed the relevance of LDL particles, emphasizing their role as the main drivers of vascular disease. We did not, however, discuss how they wreak such havoc upon our blood vessels. Today we will do so.

LDL particles do wonderful things. They transport cholesterol and triglycerides to various parts of our body for fuel, storage, or even to serve as building blocks for other important molecules. They even transport vitamin E to our brains in order to enhance growth and development in infants, and proper brain function in adults. So how can something so good, be so bad? The answer lies in numbers. The aphorism “too much of a good thing can be bad” applies perfectly to LDL particles; they are necessary for a healthy body, but only in small quantities. The numbers most of us possess are so far out of range, they are literally killing us. But how? What happens when these tiny particles make their way beneath the delicate yet vital single cell layer (called the endothelium) that lines our blood vessels? Read More…

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Cholesterol and Vascular Disease: Part 2: LDL-Cholesterol is Important, but LDL-Particle Number is Far More Revealing

September is National Cholesterol Education Month. In support of this important educational initiative we are republishing our six part series on cholesterol and the role it plays in cardiovascular disease.

Note: Seventy-one million American adults have high cholesterol, but it is estimated that only one-third of them have the condition under control.

We left off with part 1 of the Cholesterol and Vascular Disease blog concluding that the two key assumptions made by cholesterol scientists in the 1940s and ‘50s were wrong. These assumptions were: 1. All LDL particles are the same size and 2.  All similarly-sized LDL particles have the same cholesterol content. Had these assumptions been correct there would have been no need to evaluate any other LDL parameter beyond LDL cholesterol. Given the fact that they are wrong however, means that looking simply at LDL cholesterol allows for the persistence of significant and dangerous “hidden risk”.  And risk that is hidden is risk that will not be corrected. Therefore we must dig deeper into this issue and how it can translate into a higher risk for developing arterial plaque.

First, let’s deal with the size issue. We now know that many individuals have very small LDL particles, while others have large, normally-sized particles. The larger the LDL particles, the more cholesterol they can fit within them. Smaller particles on the other hand cannot carry nearly as much cholesterol as their larger brethren. (That is simple enough. A large bucket holds far more water than a tiny cup.) Read More…

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Cholesterol and Vascular Disease: Part One – The History of Cholesterol

September is National Cholesterol Education Month. In support of this important educational initiative we are republishing our six part series on cholesterol and the role it plays in cardiovascular disease.

Note: Seventy-one million American adults have high cholesterol, but it is estimated that only one-third of them have the condition under control.

For over twenty years I have practiced and taught Cardiology. Starting in the invasive and hospital-based world (performing angioplasties, stents, atherctomies, lasers, and electrophysiologic procedures) and then segueing into prevention, cholesterol abnormalities, and cutting-edge non-invasive imaging of the carotid and coronary arteries, I have had the unique and great fortune to participate in exceptionally diverse aspects of cardiovascular health and illness. I have learned a great deal along the way and some of these experiences have been shared in articles and books I’ve written. Now I’d like to clarify one of the murkiest issues I’ve encountered in all my years of practice – the cholesterol conundrum. This post is the first of a series that will hopefully clarify the cholesterol debates that currently perplex numerous patients and physicians.

In the early 1900s a young medical student named Anitschkow made the initial association between cholesterol and vascular disease. He fed unsuspecting rabbits a high cholesterol diet. After they had enjoyed a number of tasty meals he sacrificed them in order to examine their aortas (the very large blood vessel that runs from our heart to our legs). What he found was revolutionary. The rabbits that consumed their normal low fat diets were just fine, but the cholesterol-fed rabbits had all developed severe plaques in their aortas. Of course none of the rabbits was lucky (they were all killed) but had they been allowed to live, the ones with normal diets would have done great, while those who had consumed large quantities of cholesterol would have suffered from heart attacks, strokes and premature death. Read More…

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