MUSIC PLAYING:
JOHN WHYTE: Welcome, everyone.
I'm Dr. John Whyte, Chief
Medical Officer at WebMD.
Today I want to talk
about high cholesterol,
hyperlipidemia.
What does it mean?
Why does it occur?
How do you treat it?
What are the consequences of it?
A lot to cover.
So to provide some insights,
I've asked two experts.
Dr. Martha Gulati, she's
the President-elect
of the American Society
for Preventive Cardiology.
And Dr. Ann Marie Navar, she's
an associate professor
of Cardiology at UT Southwestern
Medical School.
Doctors, thanks for joining me.
MARTHA GULATI: Thanks for having
us.
ANN MARIE NAVAR: Pleased
to be here.
Thank you.
JOHN WHYTE: Let's start off
with--
we use different terms
in medicine, high cholesterol,
hyperlipidemia,
hypercholesterolemia--
what do we mean when we tell
a patient you have
high cholesterol?
MARTHA GULATI: Well, I think
in simplest terms
it means you have too many
lipids in your blood
circulation.
And mostly we're talking
about the bad cholesterol
when we give that diagnosis
to people.
And the way to think of it
is that it's the beginning--
it's what causes
atherosclerosis.
So the plaques that get formed
in the coronary arteries
are affected predominantly
by lipids.
And so high cholesterol
is something we need to treat.
JOHN WHYTE: Dr. Gulati mentioned
bad cholesterol.
What we would refer to as LDL,
or low density lipoprotein.
But there's other types
of cholesterol as well.
ANN MARIE NAVAR: Sure,
so the first thing I'll say
is that when you get
your cholesterol report,
you'll usually see
several different pieces.
The first one, total cholesterol
is kind of useless because it's
combining something good
and something bad.
So what really matters is
the subtractions of cholesterol.
There's two types of cholesterol
that we consider
bad in the sense
that they're the cholesterol
particles that get
into the artery walls and cause
heart disease.
That's LDL and VLDL--
very low density lipoproteins.
There's also HDL.
And HDL are different kind
of cholesterol particles,
but that when you actually want
to be high because higher
HDL lowers your risk of heart
disease.
The final thing that we measure
when we check cholesterol
is triglycerides.
And that's the amount
of circulating fat in the blood.
And it's related to heart
disease.
Higher triglycerides increases
your risk of heart disease.
And it's another risk factor
that we pay attention to when
we're trying to understand
somebody's risk of heart
disease.
JOHN WHYTE: Now Dr. Gulati, I
want to ask you about risk
factors
because our understanding
of risk
has changed
over the last few years.
We used to think it was all--
what you ate.
And then we saw more
of the contribution of genetics.
MARTHA GULATI: Well, that's
a fair question.
It depends on the individual
would be my answer.
But it's a little bit of both.
Of course,
we our genetic predisposition
may make it that we make more
cholesterol and we can't get rid
of it as well as somebody else.
But additionally, cholesterol
is influenced by what we eat as
well.
When we're assessing risk
we want to know what's
your lifestyle, but we also need
to know your genetics.
We need to know
about your family history
of heart disease,
specifically if you've had what
we call a premature risk
of a heart disease.
Meaning a first degree relative
who has heart disease.
If it's a male relative
before the age of 55
or a female relative
before the age of 65.
And all of it's important
because all of it
will ultimately influence both
how we not only diagnose
you or determine if you're
at risk,
but also how we attack
your cholesterol.
JOHN WHYTE: Well, I want to get
to that point of diagnosis.
High cholesterol
is asymptomatic.
People don't have symptoms
as they might with a fast heart
rate or atrial fibrillation.
So who should be screened
for high cholesterol?
MARTHA GULATI: Well, I think
everyone needs to be screened.
We know in the United States
that nearly 70 million adults
have an LDL above 130.
So we need to be screening
early--
JOHN WHYTE: But what does
everyone mean?
Is there an age break off,
a 21-year-old is different
than a 30-year-old,
different than a 40-year-old?
Some of it is based on a risk.
Do you have an age cutoff?
MARTHA GULATI: I do.
I think that age 18
and above every
adult needs a cholesterol.
Doesn't mean they
need it every year.
It depends on what
that initial cholesterol shows
you.
But actually we now even
have guidelines for children
to get screening
of their cholesterol,
particularly when they have
a strong family history
of early heart disease
in the family
that they should get screening.
JOHN WHYTE: And what's the risk
of high cholesterols?
A lot of people
will be like I know so-and-so's
cholesterol is way worse
than mine and they're fine.
Why should I worry
about high cholesterol?
ANN MARIE NAVAR: The response
I have to those folks
is we also know lots of people
who smoke and who are overweight
who never develop heart disease.
So just because some people get
away with it, doesn't mean
that everybody can.
JOHN WHYTE: I want to ask you
both about treatment,
because treatment can be
complicated whether it's
for primary prevention
for persons who have not had
a heart attack or other heart
disease
versus secondary prevention.
That is persons who have already
had heart disease.
And our evolution of treatment
has changed, hasn't it?
MARTHA GULATI: Well, the latest
is, I think it's
important for people
to understand first that we have
lots of great trials
about treating cholesterol,
particularly
in the primary prevention arm.
And I think that for that group
the first-- if there's two
things, first,
you need to know if you're
at risk for heart disease
and cholesterol
is just one part
of that component.
But if you are determined
that you need treatment
and that takes into
account a lot
of different things,
including your cholesterol.
The first medical treatment
is statin therapy.
That is part of our guidelines.
Probably the most randomized
clinical trials in all
of medicine
are related to statin, showing
that if we can lower
your cholesterol
there's a reduced risk
of cardiovascular events.
And by reducing
your cholesterol,
I mean specifically reducing
your LDL, the bad cholesterol.
JOHN WHYTE: But do you give
a trial of diet first.
What are we saying
about treating cholesterol
with diet, recognizing there's
a strong genetic component as
well?
MARTHA GULATI:
For certain people who
genetically make
high cholesterol,
and even though they might have
an excellent diet, if they have
an LDL above 190 we know there's
probably a genetic component
to that.
And they are going to need
medication, but it doesn't mean
we don't recommend also diet
as part of their therapy.
The other groups where their LDL
is in a different range
under 190,
at that point, we can always
say, OK let's see what you can
do with lifestyle but it's going
to depend on the individual.
JOHN WHYTE: How much time do you
give them.
MARTHA GULATI: Well, you need
to keep a close eye on people
because the only way for them
to be accountable to change
is seeing them soon.
And so in general, we usually
will see them after six weeks
to see what improvements they
have made.
JOHN WHYTE: And then how does
your treatment regimen change
for secondary prevention,
those persons who have already
had a heart attack?
ANN MARIE NAVAR:
So for those people
it's actually a lot easier
because in primary prevention
you're trying to sort of guess
who already has heart disease
or who's going to get heart
disease.
So we have a lot of tools
to make it a very educated
guess.
We also in that group,
we certainly recommend diet.
But we would recommend diet
and cholesterol lowering therapy
at the same time
because you want to drive down
risk as quickly as possible
so you maximize the benefit
and lower the chance
of another event.
JOHN WHYTE: Dr. Gulati,
have you ever taken a patient
off a statin
in either primary or secondary
prevention in terms of meeting
some goals, not in terms of side
effects or intolerance?
MARTHA GULATI: In general, very
few patients have I taken off
a statin.
Certainly patients again,
if they decide themselves
that they don't want to be
on it, then it's a conversation
we have about again the risks
and benefits.
If I tell them
this is a lifelong medication
that they're going to be on even
if they make amazing changes.
I want them to still make
those amazing changes as well
because that will lower
the risk.
But it doesn't always mean
that they're going to get rid
of this statin.
And it's really important
to talk about that up front when
we start these medications.
JOHN WHYTE: Let's talk
about side effects.
MARTHA GULATI: I think the issue
related to the side effects,
the muscle aches and pains
that you commonly hear about
related to statins.
If they experience them we need
to talk about them,
we need to figure out what did
they have before they even
started the statin,
and try to see if we need
to reduce
the dose of the medication,
or take other strategies to see
if they can tolerate
the medications better.
JOHN WHYTE: Some patients are
saying they have issues
with memory
after starting to statin.
ANN MARIE NAVAR: So we hear that
too.
It's reported less
than the muscle aches.
But it's actually something
that's been studied in a number
of different studies,
not just sort of vague memory
fog, but actually putting people
through a test of cognition,
including people who already
have memory impairment.
And in meta analysis of all
of these studies we have not
seen any sign that statins cause
memory loss
or cognitive impairment.
The important thing to remember
when we're talking
about the brain though,
is that statins are one
of the best treatments
to prevent stroke, which
is the leading or a leading
cause of cognitive dysfunction.
JOHN WHYTE: So you start
a statin, your LDL is still
high, what's the next step Dr.
Navar?
ANN MARIE NAVAR: Well,
the first step is to make sure
that you're taking it.
The number one thing that we see
in clinical practice for why
an LDL does not go down
on statins is that people are
taking it.
But if they're taking
their statin there are people
whose cholesterol starts up so
high that they don't get
a significant enough reduction,
or they still have room to go
after they've experienced
their initial reduction
on statin therapy.
And there we've seen really
dramatic progress in the last 5
to 10 years
with a number
of additional therapies.
Both pill therapies
and injectable therapies that we
can use to further lower
LDL cholesterol that add
on to the statin
to increase the benefit of LDL
lowering.
JOHN WHYTE: And that's
relatively
risen in the last few years.
Is that correct?
ANN MARIE NAVAR: So we've
had non-standard therapies
for a while.
What happened in the last five
years is we actually started
to get some clinical trial data
to show that it worked.
So we have data that ezetimibe,
which is not a statin, when you
add it to statin therapy
can further lower your risk
of heart disease.
We have two different injectable
therapies that are called PCSK9
inhibitors that also lower
the risk of heart disease
and dramatically lower LDL
cholesterol.
And there's a couple
of new therapies
that are coming onto the market
that we don't have what we call
outcomes data for.
So we don't know the degree
to which they lower the risk
of heart attack.
But we know that they lower LDL
cholesterol.
And that includes bempedoic acid
as well as
a long acting injectable
medication called inclisiran.
JOHN WHYTE: Dr. Navar, patients
are listening.
They've been told have
high cholesterol, they never
have any symptoms, didn't expect
it, it's a little bit of a shock
to them.
Never had a heart attack.
What do you tell them?
ANN MARIE NAVAR: The first thing
I tell them it's probably not
their fault.
And we say you can't pick
your parents.
The majority of our blood
cholesterol level is determined
by how much our body makes which
is programmed in our genes.
So the first thing I think
is important to do
is remove the stigma that it's
somehow a lifestyle disease
or something that the patients
are or are not doing.
I try to spin it
in a positive light
because it's not like we're
telling somebody that they have
a risk factor and there's
nothing we can do about it.
In fact, it's almost
an embarrassment of riches,
the number of therapies
that we have available to us
that not only lower cholesterol,
but can lower your chance
of having a heart attack.
JOHN WHYTE: Dr. Navar, Dr.
Gulati, I want to thank you
for taking the time today
to talk about high cholesterol,
explain, what causes it,
how do we diagnosis,
and how do we treat it,
and what's the role
of lifestyle?
We've covered a lot.
So thanks for the insights.
MARTHA GULATI: Thank you.
ANN MARIE NAVAR: Thank you.