LDL Goals, LDL values, and risk of heart disease
| LDL Cholesterol Level |
|
LDL Cholesterol Category |
| Less than 70 mg/dL |
|
Optimal goal for those at highest risk of heart disease |
| Less than 100 mg/dL |
|
Optimal goal for most individuals |
| 120-129 mg/dL |
|
Near optimal/above optimal |
| 130-159 mg/dL |
|
Borderline high |
| 160-189 mg/dL |
|
High |
| 190 mg/dL and above |
|
Very high |
Sources: Expert Panel on Detection Evaluation, and Treatment of High Blood Cholesterol in Adults, "Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel iii), "JAMA 285 (2001): 2486-2497; Scott M. Grundy et al, "Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines," Circulation 110 (2004): 227-239 |
LDL: How low should you go?
For the optimal prevention of heart disease, what is the ideal LDL cholesterol value to strive for? The consensus among the medical community appears to be that lower is better, especially for those at high risk for heart disease.
If you have been diagnosed with heart disease, then an LDL level of less than 70 mg/dL is a wise goal in order to halt the progression of atherosclerosis. If you are currently in good health and want to stay that way, you should aim for an LDL value of under 100 mg/dL.
How statins lower LDL
Statin drugs (Lipitor, Zocor, Mevacor, Crestor, Pravachol) are powerful presciption pharmaceuticals that lower circulating LDL cholesterol by inhibiting the key cholesterol - producing enzyme, HMG-CoA reductase, in the liver. Less cholesterol is produced by the liver cells, leading to an increased production of LDL receptors. More LDL receptors promote greater clearance of LDL from the bloodstream, the end result being a drop in your LDL value. And to a lesser extent, less cholesterol is packaged into VLDL, meaning less LDL is formed in the bloodstream.
Statins dramatically lower LDL levels fast. They are hailed by many in the medical world because they not only lower circulating LDL levels but also significantly lessen the inflammatory response within the arterial wall (as evidenced by a decline in the level of C-reactive protein). Ultimately, statin drugs save lives. They are considered by many in the medical establishment to be the wonder drugs of the twenty-first century.
Statins saves lives, but are they safe?
"My doctor has me on a low-dose statin, but my LDL just won't go down to where she wants it. She would like me to up my dosage, but I am afraid of the terrible side effects I have been reading about."
Several of my patiens have expressed concern not only with the potential for serious side effects but also with the safety of America's supply of prescription drugs in general. Statins are the first choice drug for patients at high risk of cardiovascular disease and are used safely by millions of people around the world. However, as with any prescription medication, there are side effects; in rare instances they can be serious and even fatal. Here are some statin facts you may not be aware of.
• The majority of LDL cholesterol lowering occurs with the lowest statin dosages (10 mg). Up the dose and you get diminishing returns. Doubling the statin dosage results in only an additional 5-6 percent drop in LDL cholesterol. Another good reason to question upping your dose of statins is that taking a higher dose significantly increase the potential for side effects.
• All statins have some risk associated with them. Just how much risk? Case in point: the recent rash of bad press surrounding Crestor, the strongest member of the statin family, has caused much anxiety. High doses of Crestor have resulted in reports of a rare and potentially fatal muscle disorder, known as rhabdomyolysis, that can cause kidney failure. Asian Americans, in particular, were found to be at increased risk for severe complications from higher doses of Crestor. What's more, another cholesterol - lowering drug, Baycol, was voluntarily pulled from the market several years ago after it was linked to at least thirty-one deaths.
• The fear of side effects from statin drug therapy should be put into perspective with the understanding that the higher the dose, the greater the likelihood of side effects. Combining a statin drug with a fibrate, another type of cholesterol - lowering drug (specifically a fibrate called Lopid), is not advised because the combination is more likely to produce side effects than statins taken alone. Combining statins with niacin, another treatment option for lowering cholesterol, has also been associated with some evidence of liver problems.
• The use of statins in conjunction with a therapeutic lifestyle plan, such as Cholesterol Down, is an effective alternative to upping your statin close.
What are possible side effects to watch for?
"My doctor put me on Lipitor, but I just couldn't the side effects - I felt nauseous and my muscles ached. Is there any way I can lower my cholesterol without taking prescription drugs?"
Many of my patients have confided in me that they cannot tolerate the side effects from even the lowest-dose statin drug treatment but are concerned because their physician has recommended medication to reduce an unhealthy cholesterol level. Side effects of taking statin drugs can include headache, gastrointestinal problems, fatigue, flu-like symptoms, and myalgia (characterized by muscle weakness or unusual muscular aches and pains generally not associated with the breakdown of muscle tissue). Liver problems (detected by an abnormal increase in liver enzymes released into the bloodstream) or severe muscle problems such as myopathy and rhabdomyolysis are rare, but these potentially serious side effects have been recorded in statin therapy patients.
Myopathy occurs when muscular weakness, aches, and pains are accompanied by significant and measurable muscle tissue breakdown. Rhabdomyolysis is when muscle involvement is so severe that the breakdown products saturate the bloodstream (as evidenced by myoglobin, a muscle protein, coloring the urine brown) and can progress to a life - threatening situation such as kidney failure.
Another potential cause for concern is the marked decrease in the blood of a compound called coenzyme Q10 (CoQ10), which has been observed in patients taking statin drugs. CoQ10 (aka ubiquinone) is found in large concentration in the energy - producing powerhouses of the cell, the mitochondria. A large amount of CoQ10 is located in the cells of the heart muscle. CoQ10 functions as a key player in transforming the energy from the food we eat into chemical energy known as adenosine triphosphate. Furthermore, CoQ10 has antioxidant properties that can help prevent the oxidation of LDL cholesterol.
Some scientists believe that the depletion of CoQ10 by statin drugs contributes to the occurrence of many of the adverse side effects discussed above. In fact, Canada requires that all statin drugs carry a warning label alerting consumers that the drugs deplete CoQ10 levels in the blood. New research is beginning to surface that bolsters the notion that statin drugs deplete cellular CoQ10 levels. Researchers at Columbia University's College of Physicians and Surgeons measured CoQ10 levels in thirty-four patients before and after placing them on a high dose of Lipitor (80 mg/day) for a period of thirty days. There was a marked decrease in the blood concentration of CoQ10 after thirty days of treatment, with the average blood level dropping by half. The researchers concluded that the depletion of CoQ10 could help explain the most common negative side effects associated with statin use.
On May 24,2002, Julian Whitaker, M.D., filed a citizen's petition to the U.S. Food and Drug Administration to change the statin labels so that they are required to mention that HMG-CoA reductase inhibitors (statins) block the synthesis of CoQ10, which may have deleterious side effects. He suggests that all patients be encouraged to take CoQ10 supplements, which are very safe. Unfortunately, on March 4, 2005, the FDA denied Dr. Whitaker's petition. In the meantime, until there is enough research to prove that supplementation with CoQ10 mitigates statin - included muscle problems, I continue to recommend that my patients take a CoQ10 supplement with any statin drugs.
The bottom line on statins
Statin drugs are generally safe and have become the essential treatment for those at high risk for heart disease. High doses cut LDL to ultra-low values, yet you must heed the caveat: high dosages increase the risk of serious side effects. There is a solution to this problem. The goal should be to get LDL to target levels, using the lowest dose possible. If a high-dose statin is advocated but you are wary of or cannot tolerate taking the higher dosage, consider adding in a more natural strategy. The Cholesterol Down Plan, combined with your lower-dose statin drug, may be the perfect means to help you reach your LDL goal.
Statins alone are not enough
"My doctor has me on a statin pill. My cholesterol dropped from 290 to 180 mg/dL, so I can pretty much eat whatever I want." This particular middle-aged male patient has a strong family history (both parents died of heart disease), is overweight (with the fat concentrated around his belly - a dangerous location), doesn't exercise, and eats a heavy meat-based, high-fat, low-fiber diet. My guess is that the statin drugs will not fully protect him against succumbing to heart disease before his time, despite the significant drop in his cholesterol level. I see this quite often and call it the "statin mentality." It is human nature to look for a quick fix, a Band-Aid approach that salves the guilt and allows for continuation of an unhealthy lifestyle, masking the reality of the situation. Don't fool yourself into thinking that taking a daily statin pill will reverse the effects of the atherosclerosis - including lifestyle that is all too typical among Americans. How many times do you order a thick slab of prime rib, a baked potato smothered in butter, and a gargantuan slice of New York - style cheese-cake and think, "I better take my Lipitor with my coffee"? This type of behaviour is not exactly heart-healthy. In this regard, statins are not a cure-all, and their LDL - lowering effects may be over-whelmed by multiple heart disease risk factors and unhealthy lifestyle practices such as lack of exercise, a propensity for weight gain (especially around the middle), and/or a low-fiber diet full of saturated fat and cholesterol. The Cholesterol Down Plan not only helps you fight high cholesterol but also provides a diet and exercise prescription that either in combination with statin treatment or on its own helps lower these other risk factors for cardiovascular disease as well.
Diet-not drugs-should be the first line of defense
What do you do if you've tried statins to lower your high LDL cholesterol but with adverse consequences? What if you're distrustful of taking prescription drugs in general? In the wake of the Vioxx, Celebrex, Baycol, and Crestor debacles, a cautious public rightly questions whether it is really safe to follow the statin route, and Americans are beginning to search for different, healthier, and drug-free alternatives for lowering cholesterol.
The truth is that statins should not be the first line of defense against high cholesterol. Doctors are instructed by ATIP III to first initiate "therapeutic lifestyle change" - namely, diet and exercise - if their patient's LDL is above the desired goal. If diet and exercise alone fail, only then should doctors consider drug therapy. In fact, the government's NCEP report emphasizes the importance fo therapeutic lifestyle change (a heart-healthy diet, such as the Cholesterol Down Plan, employing proven cholesterol - lowering foods and exercise in addition to weight management) as the corner-stone for cholesterol management.
Several of the dietary steps in the Cholesterol Down Plan work in a drug-like fashion, almost the dietary equivalent of taking a statin, a bile acid sequestrant (such as Questran), and a cholesterol absorption blocker (such as Zetia). Take this more natural lifestyle approach and watch your LDL plummet - without the side effects!
Source: Cholesterol Down, Foreword by Jennifer H. Mieres, M.D.
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