How Low Must Your Cholesterol Go?
Who does -- and doesn't -- need cholesterol-lowering drugs.
Pretty simple, right? Wrong, says UCLA professor Prediman K. Shah, MD, director of cardiology and the Atherosclerosis Research Center at Cedars-Sinai Medical Center in Los Angeles.
It gets complicated very quickly," Shah tells WebMD. Inflammation in the artery in response to "bad" LDL cholesterol can vary from person to person, depending on factors of which we don't have a clue, says Shah. "This very simplistic notion that everybody's LDL is equally inflammatory cannot be true. This can explain why some people get heart disease at relatively low LDL levels, and some do not."
People differ in how well their HDL works, too.
"We know not only the quantity of HDL, but also the quality of HDL is important," Shah says. "If you have highly efficient HDL, good. If you have the poopy kind of HDL, it's not much help."Your Cholesterol
LDL cholesterol isn't the whole story. But it's where you have to start, Schaefer and Shah agree. So what story does a person's LDL cholesterol level tell?
"To understand the significance of a person's LDL level, one would have to look at the entire risk profile for this patient," Shah says. "If it's a high-risk patient, we would want to lower LDL to 70-85 -- we don't know the precise ceiling. So the higher the risk, the lower we would want to go with LDL lowering. The severity of intervention should match the magnitude of risk, not just the risk factor."
What's a high risk? The main risk factor is age, Schaefer says. This means 45 or older for men and 55 or older for women. That counts as one risk factor. Two risk factors give a person a 10%-20% chance of heart disease in the next 10 years. The risk factors are:
- Age 45 or more for men, 55 or more for women
- Cigarette smoking
- High blood pressure -- greater than 140/90
- Low HDL cholesterol -- less than 40 mg/dL
- A close relative who had heart disease at an early age -- before 55 for a male relative and before 65 for a female relative.
But this list -- from the National Cholesterol Education Program -- is already outdated, says Laurence S. Sperling, MD, director of the Emory Heart Center risk reduction program.
"These are minimal guidelines," Sperling tells WebMD. "Right now those guidelines in clinical practice are already outdated." Shah and Schaefer agree that other risk factors should be considered:
- Insulin resistance
- Obesity or a BMI of greater than 30
- A waist size of more than 40 inches for a man and 35 inches for a woman
- Signs of early, asymptomatic heart disease
And there's also a "very high risk" category. This includes people who already have heart disease and people who have diabetes.