Regarding cholesterol management, as a Preventive Cardiologist, the two questions my patients ask me most frequently are:
1. 'Do I need to be on a statin?'
2. What should my LDL cholesterol be.
I cover this topic in my book 'Prevention: The Most Imortant Treatment of Heart Disease', but here is a quick summary.
Statin or Not?
If you have established cardiovascular disease: suffered a heart attack or stroke; required a heart bypass surgery (CABG) or cardiac stents; been diagnosed coronary artery disease (CAD), peripheral vascular disease (PAD)...or diabetes (even without established heart disease), your doctor will prescribe a statin. There is overwhelming and unquestioned benefit of statins reducing the incidence of future cardiac events (heart attack/cardiac death). In 2018 the American College of Cardiology (ACC) and the American Heart Association(AHA) revamped the guidelines for cholesterol managment. These guidelines dictate to all U.S. cardiologists the goals of cholesterol lowering. The take home message from the guidelines was 'the lower the LDL...the better!' For many decades, all doctors have known that the lower the LDL, the lower risk of heart disease. What confused everyone in 2013 is that the ACC/AHA cholesterol management guidelines, with great controversy, focused upon the dose and type of statin--rather than the LDL.
How Low Should My LDL be if I Have Heart Disease?
For patients with established heart disease, the LDL should be targeted at <70mg/dl.
In my practice, for my patients, I further suppress LDL towards 50mg/dl with statins and 30mg/dl with PCSK9 inhibitors (FOURIER Trial). This is because the LDL cholesterol value from the lab test is almost always a calculated or indirect LDL measurement. In Hawaii, for example, it costs extra to obtain a 'direct LDL'. This direct LDL is typically 10-20 points higher than the calculated LDL. This means that if your LDL (calculated) value is 70, your true LDL (direct LDL measurement) is probably closer to 80-90mg/dl.
In summary, for cardiac patients, your LDL should be aggressively suppressed in order to prevent future cardiac problems.
Do I Need a Statin if My Cholesterol is Elevated, But I Do Not Have Established Heart Disease?
I review the cholesterol management guidelines with all patients during their visit because they can be confusing...even for doctors. There is a problem with the ACC/AHA Cholesterol Management Guidelines because it continues to advocate the use of a cardiac risk calculator. This calculator uses traditional risk factors to estimate your 10 year risk of having a heart attack or dying from one. The problem? The calculator may overestimate your cardiac risk by 50-70%.
How Do I Know if I Even Have Heart Disease? The Calcium Score
All doctors and insurance carriers have known for nearly 30 years that the need for a statin is based upon the presence of heart disease.
If no disease is present, then a statin is not needed.
If CAD is present, take statin and aspirin (aspirin only if LDL is elevated) and lower LDL<70mg/dl.
In fact, the 2018 cholesterol management guidelines advocates a decades old test—one that I have advocated for over 29 years—known as a calcium score. The calcium score determines the presence of absence of heart disease by detecting calcifications within your coronary arteries. This study may not be reimbursed by your insurance carrier so you may have to pay out-of-pocket. The cost is usually under $200 dollars in Hawaii (Around $70 dollars on the mainland!)
Note: Understanding your heart condition is not difficult. Patients become frustrated and confused when doctors don’t explain things clearly. If you don’t understand what your doctor is talking about, then you won’t be able to ask meaningful questions. I hope that my posts provide you with a framework that you can build upon to become an active participant in your healthcare.
Stay Healthy!
Gregg Yamada MD
Disclaimer: I hope you find my medical blogs to be educational, pertinent, interesting, and thought provoking. The information provided is educational and should not be taken as medical advice. I am a doctor, but I am not your doctor. Please schedule an appointment with your doctor to discuss these issues and to determine what is right for you.
© 2022. Gregg M. Yamada, MD FACC. All rights reserved