DEAR READERS: You've sent me lots of correspondence about the new statin guidelines. Most have come from people whose doctors put them on statins because of the new guidelines. In October 2015, I discussed the new guidelines in two columns and said I'd keep you up-to-date about any important new information.
DEAR DOCTOR K: Despite taking statins, my cholesterol hasn't dropped as low as my doctor would like. I figured he'd put me on the new PCSK9 inhibitors. Instead, he suggested that I stay on my statin, but also take another drug called ezetimibe. What can you tell me about this combination?
DEAR READER: From what you say, I assume your doctor has used the highest dose of the most potent statins before giving up on those drugs. There are very few people whose cholesterol does not drop substantially on statins alone.
DEAR DOCTOR K: I have high cholesterol and high blood pressure, so I know I'm at increased risk for heart disease. Should I see a cardiologist?
DEAR READER: For many people, a primary care physician (PCP) can effectively manage standard risk factors for heart disease. Your PCP also will know when you need to see a cardiologist, and can refer you to a particular one.
DEAR DOCTOR K: I have high levels of HDL cholesterol -- the "good" cholesterol. I was happy about that, but now I hear that medicines raising your HDL levels don't seem to help. Should I be disappointed?
DEAR READER: The HDL cholesterol story is complicated. It has been solidly established that people who have high levels of LDL (bad) cholesterol have a higher risk of developing heart disease. Moreover, it has been solidly established that treatments that lower LDL cholesterol reduce the risk of developing heart disease.
DEAR DOCTOR K: My recent cholesterol blood test came back pretty good, but my doctor said he was worried about my high triglyceride levels. What are triglycerides? Should I be worried, and what can I do about this?
DEAR READER: When doctors perform cholesterol blood tests, they actually test for LDL ("bad") cholesterol, HDL ("good") cholesterol, total cholesterol (a combination of good and bad cholesterol), as well as triglycerides --another type of fat. Levels of triglycerides that truly are high increase your risk for pancreatitis, an inflammation of the pancreas, as well as heart disease and stroke.
DEAR READERS: In yesterday's column I began to answer a reader's question as to what I thought about the new statin guidelines. Today, I finish my necessarily long-winded answer. Statin drugs have (at least) two powerful effects. They lower blood levels of LDL cholesterol (so-called "bad" cholesterol). They also fight inflammation. Old guidelines said doctors should prescribe statins for people whose LDL cholesterol levels were high. New guidelines say that doctors should prescribe statins to people who are at high risk for heart disease, even if their LDL cholesterol levels are not high. These guidelines are controversial.
DEAR DOCTOR K: My doctor put me on a statin in 2013 because the guidelines that came out that year said I should be on them. Are the new guidelines really better than the ones they replaced?
DEAR READER: I'm sorry you asked that question, because any answer I give will be criticized by some of my colleagues on the faculty of Harvard Medical School. This is a very controversial area, and my colleagues all have strong opinions -- just not the same one.
DEAR DOCTOR K: My cholesterol is high and my doctor wants me to go on a statin. I'd like to avoid medication. Do any supplements effectively lower cholesterol?
DEAR READER: Statin drugs lower LDL (or "bad") cholesterol and also reduce inflammation. Together, these effects lower your risk of heart attack. Various herbs and supplements have been touted for their ability to improve cholesterol levels. There is one general caveat you should consider. New drugs are tested by the FDA for their safety, effectiveness and purity.
DEAR DOCTOR K: I have high cholesterol, but I can't tolerate statins. Are there any new treatments for lowering cholesterol?
DEAR READER: I assume you're taking statins because your low-density lipoprotein (LDL) cholesterol (so-called "bad" cholesterol) is high. If so, that does increase your risk of having a heart attack or stroke. Lowering LDL cholesterol reduces that risk. Some people can bring down their cholesterol levels with diet and exercise alone. But many people need medication to get to their target levels.
DEAR DOCTOR K: Does the amount of cholesterol you eat affect the cholesterol levels in your blood?
DEAR READER: I'm glad you asked this question, because I think doctors and the news media have not made it clear. For decades, doctors and food scientists have warned against the dangers of eating foods high in cholesterol. That seemed to make sense. First, high blood levels of so-called "bad" (LDL) cholesterol definitely are bad for your health. Second, it seems logical that the more cholesterol you take into your body when you eat, the higher the cholesterol in your blood. But there's growing agreement among nutrition scientists that cholesterol in food has little effect on cholesterol in the bloodstream.