Learn about your Lipid Profile:

Why? High lipid levels put you at risk for heart attacks and strokes. Learn the facts BEFORE you have symptoms. Cardiovascular disease can begin as early as age three if there is a family history of heart disease or high cholesterol. There has been ample evidence since the 1900's that people with high cholesterol develop more heart attacks. The first and foremost, Framingham Study, influenced our current theory of heart disease. It showed that people with high cholesterol have more heart attacks. 
Another ground breaking study: known as the Scandinavian Study, of 4,444 people with heart disease was done between 1990 and 1994. One group of 4,444 took no medication and another group of 4,444 took simvastatin (Zocor), a cholesterol lowering medication for 4 years. Those who took simvastatin (Zocor) showed a 30 to 40% reduction in sudden death due to recurring heart attack or stroke. Their cholesterol was lowered. This proved the relation between cholesterol and cardiovascular disease.

Your lipid levels should be:

According to the guidelines by the NCEP-ATP III (National Cholesterol Educational Program, Adult Treatment Panel III), released May 2001: 
     - Total Cholesterol: Under 200 mg/dL (best below 150)
     - LDL: Under 100, Ideal below 70
     - HDL: Over 45 for women, over 40 for men
     - VLDL: Under 40

What is a lipid profile?

The lipid profile is a group of tests that are often ordered together to determine risk of coronary heart disease. The tests that make up a lipid profile are tests that have been shown to be good indicators of whether someone is likely to have a heart attack or stroke caused by blockage of blood vessels (“hardening of the arteries”).

What tests are included in a lipid profile?

The lipid profile includes total cholesterol, HDL-cholesterol (often called good cholesterol), LDL-cholesterol (often called bad cholesterol), VLDL–or very low-density lipoproteins and triglycerides. Sometimes the report will include additional calculated values such as HDL/Cholesterol ratio or a risk score based on lipid profile results, age, sex, and other risk factors.

How is a lipid profile used?

The lipid profile is used to guide providers in deciding how a person at risk should be treated. The results of the lipid profile are considered along with other known risk factors of heart disease to develop a plan of treatment and follow-up. 

Total blood cholesterol level:

Your total blood cholesterol will fall into one of these categories:
     - Desirable -- Less than 200 mg/dL
     - Borderline high risk -- 200-239 mg/dL
     - High risk -- 240 mg/dL and over

Desirable:
If your total cholesterol is less than 200 mg/dL, your heart attack risk is relatively low, unless you have other risk factors. The latest medical consensus recommends striving for 150 mg/dl or less. Even with a low risk, it's still smart to eat foods low in saturated fat and cholesterol, as well as get plenty of physical activity. Have your cholesterol levels measured every five years -- or more often if you're a man over 45 or a woman over 55.

Borderline high risk:
If your total cholesterol level is from 200 to 239 mg/dL, it is borderline high risk. About a third of American adults are in this (borderline) group; almost half of adults have total cholesterol levels below 200 mg/dL. In general, people who have a total cholesterol level of 240 mg/dL have twice the risk of heart attack as people whose cholesterol level is 200 mg/dL.

Have your cholesterol and HDL rechecked in one to two years, if:
     - Your total cholesterol is in this range
     - Your HDL is less than 40 mg/dL
     - You don’t have other risk factors for heart disease  

You should also lower your intake of foods high in saturated fat and cholesterol to reduce your blood cholesterol level to below 200 mg/dL. Your doctor may order another blood test to measure your LDL cholesterol. Ask your doctor to discuss your LDL cholesterol with you. Even if your total cholesterol is between 200 and 239 mg/dL, you may not be at high risk for a heart attack if not other risk factors are present.

High risk:
If your total cholesterol level is 240 or more, it's definitely high. Your risk of heart attack and stroke is greater. You need more tests. Ask your doctor for advice. About 20 percent of the U.S. population has high blood cholesterol levels.

Remember: for every 1% of your cholesterol reduction you decrease by 2% the chance of heart attack or stroke.

LDL Cholesterol Level:

Your LDL cholesterol numbers are the best indicator of your risk level. Your LDL cholesterol will fall into one of these categories:  
     - Less than 100 mg/dL -- Good. Optimal under 70
     - 100 to 129 mg/dL --  Above Optimal
     - 130 to 159 mg/dL -- High
     - 160 to 189 mg/dL -- Very High
     - 190 mg/dL and above -- Extremely High

Your doctor may prescribe a diet low in saturated fat and cholesterol, regular exercise and a weight management program if you're overweight. If you can't lower your cholesterol with these efforts within 3 months, medications may also be prescribed to lower your LDL cholesterol.

Your VLDL level is extremely important. This should not exceed 40 mg/dL. This fraction of the LDL is the most damaging to the endothelium (lining of the arteries).

HDL Cholesterol Level:

In the average man, HDL cholesterol levels range from 40 to 50 mg/dL. In the average woman, they range from 50 to 60 mg/dL. HDL cholesterol that's less than 40 mg/dL is low. Low HDL cholesterol puts you at high risk for heart disease. Smoking, being overweight and being sedentary can all result in lower HDL cholesterol. If you have low HDL cholesterol, you can help raise it by:  
     - Not smoking.
     - Losing weight (or maintaining a healthy weight). 
     - Being physically active for at least 30-60 minutes a day on most or all days of the week.
     - One glass of red wine with dinner may be helpful.
     - Using certain medications such as Niacin compounds.

People with high blood triglycerides usually have lower HDL cholesterol and a higher risk of heart attack and stroke. This is commonly seen in the metabolic syndrome and diabetes (See lesson five)  

Cholesterol ratios: The first step in determining your risk for heart disease is to know your total blood cholesterol level. The critical second step is to know your HDL or "good" cholesterol level.

Cholesterol to HDL ratio: The American Heart Association recommends that absolute numbers for total blood cholesterol and HDL cholesterol levels be used. They're more useful to the physician than the cholesterol ratio in determining the appropriate treatment for patients. Total cholesterol to HDL ratio may be obtained by dividing the HDL cholesterol level into the total cholesterol. For example, if a person has total cholesterol of 200 mg/dL and an HDL cholesterol level of 50 mg/dL, the ratio would be stated as 4:1. The goal is to keep the ratio below 5:1; the optimum ratio is 3.5:1.

Non-HDL cholesterol is obtained by subtracting the HDL values from the total cholesterol. According to the NCEP-ATPIII, it should be below 130 in people with more than 2 risks factors. The non-HDL cholesterol level has more predictive value than the measurement of any of the other lipids. It reflects the apo-B lipoprotein levels, which are the most potent atherogenic particles of all lipids. The apo-B lipoprotein is difficult to measure; therefore the calculation of the non-HDL cholesterol is more practical, inexpensive, and easy to do. (Glenn Hirsch, Johns Hopkins Hospital, Baltimore 2002)

Triglyceride Level:

     - Less than 150 mg/dL -- Normal
     - 150-199 mg/dL -- Borderline-high
     - 200-499 mg/dL -- High
     - 500 mg/dL or higher -- Very high

Many people with high triglycerides have underlying diseases or genetic disorders. If this is true for you, the main therapy is to change your lifestyle. This includes controlling your weight; eating foods low in saturated fat and cholesterol, exercising regularly, not smoking, and drinking less alcohol. People with high triglycerides may also need to limit their intake of carbohydrates to no more than 45-50 percent of total calories. The reason for this is that carbohydrates raise triglycerides and lower HDL cholesterol. Use products with monounsaturated and polyunsaturated fats. (Refer to Lesson Four) 

What influences lipid level numbers?

Diet: A diet rich in vegetables, whole grains and pigmented vegetables will help you to keep your lipids at the correct levels. (Refer to Lesson Three and Four)

Stress Level: We now know that chronic or severe stress has an impact on heart disease. The hormones that are produced when one is severely stressed contribute to the formation of plaques, which clog arteries. (Refer to Lesson Seven)

Exercise: Exercise helps to raise your HDL, maintain your weight, and reduce stress. In fact, one study showed consistent exercise to be as effective as an anti-depressant for some people. (Refer to Lesson Six)

Genetic Factors: Certain people have an inherited the tendency to have high lipid levels. For people with a family history of high lipids, diet alone cannot reduce the numbers. Remember, only 1/3 of the cholesterol on your blood comes from your diet. The other 2/3 comes from your liver. (Refer to Lesson Eight)

Medication: We now have significant evidence that statins and other medications, fibric acids, bile sequestrans and niacin raise HDL and lower LDL and decrease inflammation. There are relatively few side effects to these medications. (Refer to Lessons Two and Nine)

Inflammation: The inflammatory process precipitates arteriosclerosis. Inflammation causes accumulation of lipids on the walls of the arteries to occur faster and at a more premature rate than normal. Inflammation occurs with bacterial or viral infections such as influenza, pneumonia, chlamydia, and gum infections. There are recent studies that indicate that people with normal cholesterol and low LDL that have high levels of biomarkers for "inflammation" have a threefold higher risk of events. There are two important "biomarkers" at present:  High sensitive C-Reactive Protein (hs CRP),  normal if under 2.5 mg. and a lipoprotein-associated phospholipase A2 (Lp-PLA2), normal if under 320 ug/L. The Lp-PLA2 is a new blood test currently being studied. The ARIC Study, (Atherosclerosis Risk in Communities ) is dealing with the subject;  it has been in progress for the past six years and the final conclusions are forthcoming. (Refer to Lesson Nine)

Common questions:

Q: What medications lower lipids?
A: Many. See list below:

      Statins or HMG-CoA Reductase Inhibitors:     
      -Lipophilic: Simvastatin (Zocor),  Atorvastatin (Lipitor) ,  Lovastatin (Mevacor)
      -Hydrophilic: Pravastatin (Pravachol)  - Fluvastatin (Lescol)  - Rosuvastatin (Crestor) recently approved by the FDA

      Non-statins:

      Cholesterol absorption blockers
      Fibric acid derivatives
      - Gemfibrozil (Lopid)
      - Fenofibrate (Tricor)
      - Clofibrate (Atromid S)

      Ezetimibe (Zetia)

      Bile acid sequestrans  
      - Colestipol (Colestid)    
      - Closeveleam (WelChol)
      - Cholestyramine (Questran)

      Nicotinic acid derivatives:
      - Niacin (Niaspan)
      - Slow-Niacin
     
      Combined preparations

     -Vytorin ( Simvastatin + Ezetimibe ), Advicor ( Niacin + Lovastatin )

  

Q: How do the medications for high cholesterol work? 
A: One type of medications blocks production of cholesterol by the liver: such as statins and niacins. The other type traps the cholesterol in the bowel and prevents its absorption. Both are commonly used.

Q: Besides lowering lipids levels, do statins play any other protective role ?

A: Yes. Through their  pleomorphic effects, statins have demonstrated to produce the following benefits:

-Anti-inflammatory action, possibly by reducing the LDL oxidation. It lowers elevated CRP (index of inflammation).

-Protect the endothelium of the arteries, regenerating it .

-Vascular-dilating effect on the arteries by inhibiting endothelin-1, a powerful vasoconstrictor. Also, by repairing the endothelium of the arteries, allow the normal production of nitrous-oxide, which is vasodilator

-Beneficial in Diabetes by lowering tissue insulin-resistance.

-Protective effect against osteoporosis. Patients on statins have less bone fractures.

-Anti-Alzheimer effect. It lessens the accumulation of Beta-amyloid in the brain.

-Lessens the formation of clots by decreasing the platelets adhesiveness.

-Stabilizes already formed plaques, preventing their tendency to break. Broken plaques initiate acute events, like heart attacks and strokes.

-Induce regression of arteriosclerotic plaques. ( "Asteroid Study" published in 2006 by S.Nissen, Cleveland Clinic).

Q: If I have normal cholesterol, should I take statin medication?  
A: Yes, if there is family history of previous cardiovascular events or if there are any other risk factors present.

Q: Are there any side effects or dangers to the medication?  
A: Compared to the benefits there are minimal risks to lipid lowering medications. The risk ranges from between .01 and .5% of developing problems with the liver or inflammation in the muscles. Coenzyme Q10 is an antioxidant that can help to prevent muscle inflammation.  

Q: Is one statin medication better than another?
A: What is better for one person is not necessarily better for another because people have individual variations. There are a variety of medications on the market that can be prescribed to suit a person's individual needs.  

Q: What if I have a reaction to a cholesterol lowering medication?  
A: First, consult with your doctor to insure that the reaction is caused by the medication. Your doctor may lower the dosage or switch to another medication. 

Q: Can you take more than one medication to lower your lipids?  
A: Yes, some people may take both a statin and niacin. One alone may not do the job. The dosage, as well, can be varied to suit the needs of the patient. Niacin specifically lowers the triglycerides and elevates the HDL.

Q: Is there a best time to take lipid-lowering medications?
A: Yes, evenings, prior to bedtime because the peak production of cholesterol by the liver takes place after midnight.

Q: When and how often should lipids be tested?
A: At least once before age 20 and every 5 years thereafter. If there is a family history of cardiovascular disease testing should done at age 3 and above. After the age of 40, test once a year. If taking medication for high lipids tests should be done every 6 months. 

Q: Who should take medications to lower lipids?
A: Any person who has abnormally high levels of lipids, that do not come down after 3 months of a reasonable diet and exercise. Refer to Lesson One and The Framingham Table to see the need to initiate therapy depending on the presence of certain risk factors.

Q: Are there any natural products that lower lipids?

A: Yes. Fish oil Omega-3 is an excellent LDL and triglycdrides reducer. It aldso increases HDL. Natural fibrates (whole grain products) also reduce lipids levels.

Q: Are there any gender issues regarding lipids? 
A: Yes. Refer to Lesson One and Women and Cardiovascular Disease.

Revised October 30, 2009