High Cholesterol

What do you think of the changes to the statin prescribing guidelines that were made in 2014?

DEAR DOCTOR K: My doctor never recommended statins to me, but he says there are new guidelines, and thinks that I should now start taking one. What do you think of the new statin guidelines?

DEAR READER: The new guidelines make a lot of sense, because we've learned that statins have more effects on the body than just lowering cholesterol.

Do I still need to fast before a cholesterol test?

DEAR DOCTOR K: I heard that fasting will no longer be required before a cholesterol test. Will the results still be as accurate?

DEAR READER: To answer your question, I need to first describe what a "cholesterol test" is. There are three types of cholesterol that typically are measured: LDL ("bad") cholesterol, HDL ("good") cholesterol and total cholesterol (basically, the sum of LDL and HDL). There is a fourth type of fat measured at the same time: triglycerides. Most doctors order all four tests as part of what's called a "lipid (fat) panel."

Can you tell me about a drug combination my doctor prescribed to lower my cholesterol?

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.

Do I need to see a cardiologist?

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.

Do drugs that raise good cholesterol reduce the risk of heart disease?

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.

What are triglycerides?

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.

Risk factors for heart disease determine statin use

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.

Are the new statin guidelines better than the ones they replaced?

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.

Do any supplements effectively lower cholesterol?

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.