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.