Focus Topic  CARDIOLOGY

By Jane Ehrhardt

“Cholesterol is not just high or low LDL. It’s not a simple number based on a reading,” says cardiologist Saema Mirza, MD, with Cardiovascular Associates (CVA). Studies continue to uncover numerous other factors that influence the appropriate medical approach for controlling this fatty substance produced in the liver and carried through the bloodstream.

“It is not just lifestyle and diet alone. We know it’s genetic,” Mirza says. “It’s the way your body metabolizes cholesterol.” Even the expected influences based on gender, age, and lifestyle can be deceiving. For instance, among her patients, Mirza has seen active, healthy 20-year-olds with LDLs over 300.

The danger of high cholesterol lies in its building up as a plaque in arteries that can inhibit blood flow enough to cause numerous problems, including heart attacks and strokes. Worldwide, one-third of ischemic heart disease and an estimated 2.6 million deaths can be pinned on high cholesterol, according to the World Health Organization.

Currently, the reigning treatment for controlling cholesterol is statins. Taken as a pill, these medications decrease the liver’s production of cholesterol while increasing its ability to remove LDL from the blood. Approved by the FDA in 1987, statins have become so popular that by 2012, 93 percent of adults taking a cholesterol-lowering medication used a statin. As of 2023, nearly 39 million Americans take a statin daily, according to the CDC.

“Diabetics all need to be on statin no matter their LDL level, because they are at an extremely high risk for coronary heart disease (CHD) and a lot of them have silent heart disease,” Mirza says. Anyone with LDLs over 190 or with atherosclerotic cardiovascular disease (ASCVD), which includes heart attacks, ischemic strokes and vascular disease, also fall into this category.

For patients outside those three parameters, physicians can calculate the 10-year mortality risk using the American Heart Association’s formula which generates the risk percentage of having a cardiovascular event within 10 years. The outcome depends not just on the patient’s total cholesterol, age, and gender, but also race and smoking history. If the score comes to 7.5 percent or higher, high-intensity statins need to be prescribed.

If a patient scores between 5 and 7.5, then a calcium score can help to define the risk. This test can also help convince patients who need to consider taking statins for any reason. Patients who generate a calcium score more than zero, should be prompted to consider taking a statin, since more calcium in the blood means a greater risk of artery-blocking plaque. “If the calcium score is zero, statin therapy may be delayed, except in diabetics, smokers, etc.,” Mirza says.

Other conditions that up the need for statins should be considered no matter the outcome in either the calcium or the mortality risk evaluations. Besides LDLs over 160, those risk factors include metabolic syndrome, chronic kidney disease, preeclampsia, early menopause, rheumatoid arthritis, HIV, and South Asian ethnicity.

Should statins not be working to keep a patient’s LDL below 100, then add ezetimibe, which only comes in a 10 mg dosage. This medication directly reduces the amount of cholesterol absorbed from food. “Combined with a statin, these two are great for additional lowering of LDL,” Mirza says.

Should statins prove ineffective by themselves, a stronger alternative to ezetimibe is PCSK9 inhibitors. The PCSK9 protein regulates how many LDL receptors reside in the liver. People naturally high in this protein are more likely to have high cholesterol. The current PCSK9 inhibitor on the market, Repatha, is given every two weeks by injection. “It really lowers LDL levels,” Mirza says. “The data is robust, but it is very expensive, so for that reason, statins are the first line of treatment.”

The inhibitor injections also works well on its own for those with statin intolerance. “You have to be really sure someone is statin intolerant, though, because everyone has aches and pains,” Mirza says. Statins have gotten a bad reputation for intolerance, so patients’ internet searches can spark a hyper-awareness of aches and pains that get attributed to statins.

“True statin intolerance is actually extremely rare,” Mirza says. “In clinical trials, as many people on placebos complained of aches and pains as on statins. If a patient and physician think there is an intolerance, I recommend stopping the medication and waiting until the symptoms abate. Then begin the statin again at a lower dose because it is so important to take them.”

Mirza has also found that during that week or so when the patient is off statins have them take coenzyme Q10. Then keep them on the coenzyme when they restart the statin at the lower dose. “A lot of the time, the patients who said they couldn’t tolerate statins, are able to take them with CoQ10,” Mirza says. “Studies do show that it works. We just don’t yet really know how.”