Similar to the development of the DEW line (radar defense line along arctic circle in north America that was early warning for invasion from Russia) in national defense in the cold war, the use of lab tests to measure cholesterol as a predictive measure for future heart attack and stroke is important, but not sufficient to truly predict the occurrence of heart disease. All individual responses cannot just be tied to just one piece of data, like cholesterol level, because there are many factors that lead to heart disease. We need more information and we need strategies that encompass the every factor that increase the incidence of heart disease, not just one score such as a high cholesterol level, to determine whether someone should take a statin drug for the rest of their lives.
Cholesterol level is currently the one synapse answer, or the trip wire that screams trouble, when it comes to predicting heart disease. We actually need to have multiple ways to determine risk and protect our bodies the same way the military had to develop other strategies to supplement and do more than the DEW line, to make America safe in the 1950s.
When Doctors look at your lab tests before putting you on cholesterol lowering drugs, what tests do they consider risk predictors of heart attack and stroke? What do those scores tell them?
Doctors look at three key items:
- The lipid panel including total cholesterol, HDL cholesterol (good), and LDL cholesterol (bad) and triglyceride levels.
- C-CRP: a test for inflammation which is a key predictor of future heart problems
- Homocysteine (B vitamin metabolite) levels, which are genetically determined and increase with poor diet and alcohol levels. This is linked to MTHFR genetic abnormalities and cause soft plaque in vessels as well as blood clots.
Doctors may or may not get all three tests but they usually just react to cholesterol and triglyceride levels. It generally functions as an emergency alarm like a fire alarm to warn you to do something now, like begin taking a statin. Statins were billed to be no risk and beneficial to those patients with a positive family history of atherosclerosis and doctors put anyone with high cholesterol on them. Now we know they increase the risk of dementia, aging, lower testosterone and growth hormone, so we must become more selective as to who receives this medication.
Beyond lab values, doctors should look at your lifestyle, diet and exercise patterns that predict your risk of heart disease. These take a lot of time and sometimes are glossed over by physicians who can write a prescription faster than they can tell you what to eat.
Family history and genetics ( there is a rising new medical market in genetic testing for this and other concerns)are also taken into account when deciding what action a patient should take and how early they should take statins. In the future this method will be more specific and more predictive.
When it comes to deciding what to do with your doctor consider these facts:
- Total cholesterol is not a good risk factor because it is composed of the good and bad cholesterol and therefore a high cholesterol is not always bad.
- LDL is somewhat predictive and can be lowered by non-oral testosterone, thyroid, weight loss and carbohydrate restriction.
- If the only factor your doctor looks at is Cholesterol and LDL then ask if you have high inflammation (C-CRP) which is necessary for cholesterol to make plaque.
- A high homocysteine level can cause plaque without inflammation or high cholesterol but it is easy to treat. Taking methylated-B vitamins is the treatment and will prevent plaque production.
If you are over 50 and you don’t want to take statins, or have a bad reaction to them, then it is reasonable to ask your doctor to order a Cardiac CT Calcium Scan. This can be done in radiology and is a self pay test (about $250) If you have no plaque, and are over 50, then keep doing what you are doing and statins will not be necessary to prevent heart disease.
Remember there is more to predicting your chance of having heart disease than a number on a lab test. Doctors need to consider your overall health and condition, as well as your family history. That is why we recommend you find a primary care physician with whom you have a history and a relationship. Emergency medicine can save your life in a crisis, but we all need to have a relationship with a physician who knows us and in whom we trust and who is up to date with the newest tests and considerations when it comes to preventing heart disease.