You thought you’d hit the number that meant your “bad” cholesterol was under control. The doctor gives you a pat on the back – and a new goal.
“Patients may say, ‘Look, I got my LDL to the goal I said I’d get to, and now you want me to lower it?’ said Dr. Mehmet Aktas, board member of the Rochester chapter of the American Heart Association. “The answer I give them is that our bodies change. “Based on our age, our diet and other variables, things change, and our goals for what we want to achieve to improve outcomes and reduce heart disease and stroke may change.”
So does science.
“The evidence now shows that being a little more aggressive in lowering LDL is actually only going to benefit you,” said Aktas, who is also a cardiologist and arrhythmia specialist at the University of Rochester Medical Center’s Strong Memorial Hospital.
“In years past, we might have thought that an LDL cholesterol of 130 was good,” he said.
However, studies have shown that a level of 100 reduced the risk even further. And the number is constantly decreasing.
“More recently, evidence has been generated to show that LDL 70 or even lower is beneficial in patients with established heart disease,” he said. “That’s really the thing about medicine, we learn over time and challenge the status quo.”
Cardiologists and primary care providers explain to people why goals have shifted and the need for a healthy lifestyle, regardless of age or the need for medication.
“Cardiovascular disease is the number one killer,” said Dr. Gaurav Sharma, who directs the lipid clinic at the Sands-Constellation Heart Institute at Rochester Regional Health. “So it behooves us to prevent it and then mitigate the morbidity and mortality from it.”
“I tell patients that there are many different disease processes that someone could have. That’s in my opinion, at this point, more favorable to have because we can deal with it and we can prevent it.”
In 2018, the American College of Cardiology and the American Heart Association Task Force on Clinical Practice Guidelines updated their guidelines for cholesterol management.
The first recommendation is to emphasize a healthy lifestyle for everyone, regardless of a person’s age or need for medication.
Sharma explained that specific recommendations were made for people between the ages of 40 and 75, based on their current LDL level and whether they have diabetes and other risk factors. For some patients, an LDL of 70 mg/dL was used as a threshold for using drugs in addition to statins.
Then, in 2022, the American College of Cardiology made even stricter recommendations for people who had already had a heart attack or stroke.
The ACC also began providing targets for people who have never had a heart attack, and those targets were based on an estimate that factors in age, sex, blood pressure and cholesterol to calculate the 10-year risk of heart attack or stroke. For someone with less than a 5 percent risk, the recommendation is to focus on diet and lifestyle, Sharma said.
Cholesterol management and risk mitigation focuses on LDL—low-density lipoprotein that can build up in the arteries and increase the risk of heart attack or stroke. “This is really the most important culprit that contributes to the development of plaque,” Sharma said.
Approaches to controlling cholesterol start with lifestyle, whether one has had a heart attack or stroke or is practicing primary prevention to avoid such an event in the first place. “It’s pretty clear in all the instructions since I’ve been in training,” he said.
Instead of looking at what a person can’t eat, Colleen O’Brien, a registered dietitian and nutritionist at the Anthony L. Jordan Health Center, looks at what a person can enjoy to be healthy.
“That would be helpful,” he said.
Her recommendations are made in the context of family and culture.
“It’s something I talk to people about a lot. I have to figure out what is something that they are open to doing, that they are comfortable with. It’s not like they’re turning their lives upside down in terms of what they’ve been eating for 30 years.”
O’Brien said she recommends using healthier oils, reducing portion sizes, increasing vegetables and trying whole grains like brown rice instead of white.
“I’ve definitely seen people cry in my office at the idea that they have to give up certain things or change certain things. Especially if they are newly diagnosed with diabetes. It can be very overwhelming. Also, just the emotional connection to food for many people. This is something we can tackle together.”
O’Brien said she believes in the power of small changes. “When I work with patients, I want them to walk away feeling comfortable with the decision we made together.”
“If I just give them a diet recipe, I haven’t really helped them if they’re not receptive to it.”
Dr. Robert Block leads the clinical lipidology program at UR Medicine Cardiac Care. While he prescribes medication, he advocates lifestyle changes for their overall effect.
“We know that not only does it reduce the risk of heart attack, stroke and blood vessels in the lower extremities, but there may be many other benefits.”
He reported a reduced risk of diabetes, improved sleep and an overall improved quality of life. “If they lose five or 10 pounds, sometimes that makes a difference with blood pressure.”
If lifestyle changes aren’t enough, or if someone is at high risk for heart attack or stroke, then medication comes into the discussion.
Block said patients can be hesitant to try a drug for a number of reasons, including misinformation from social media or other unreliable sources. He said the updated guidelines also provide ways for providers to break down the issue and have a productive conversation.
Block also said newer drugs give cardiologists and patients more options.
“If someone doesn’t get enough of one type of drug, like a statin, or can’t tolerate the dose or tolerate a statin, there are other drug options that can be very helpful not only by lowering their cholesterol, but by lowering also the risk of heart attack and stroke.”
Even if he writes a prescription, Block still gives advice on diet and activity. “It’s a combination, and that’s the way many of us in this field have been doing it for years.”
Patti Singer is a freelance writer in Rochester. Contact her at [email protected].