When your doctor gets the results of your blood test for cholesterol— the blood lipids, or fats, that can cause the artery-clogging disease atherosclerosis— he or she may suggest a cholesterol-reducing medication called a statin. You'll also be advised to follow a healthy lifestyle, such as watching what you eat (particularly animal products), exercising regularly, controlling your weight, and of course not smoking. These steps—aimed at lowering your risk of heart disease—haven't changed much in the past decade or two. But change in the management of cholesterol is coming, says family physician Bruce Aronwald, D.O., of Saint Barnabas Medical Center, and it will be dramatic.
The reason is that new research is giving doctors a much more detailed understanding of the cholesterol in your blood, what it means and how it works. To understand this improvement, he suggests, think of your television set.
"Decades ago, when we were first becoming aware of cholesterol and its effects, we looked only at the total cholesterol count," he says. "That was analogous to those big, black and- white console TVs, which gave us a fuzzy picture without much detail. Then, in the 1980s, we started looking at cholesterol components such as HDL [high-density lipoproteins] — the 'good' cholesterol—and LDL [low-density lipoproteins]—the 'bad' cholesterol. That was analogous to a Sony Trinitron, which provided color, more detail and a clearer picture. Now researchers are looking at sub-particles of LDL and HDL and their precise impact on atherosclerosis. And that is like the new 65-inch flat screen LCD TV. Now we can see the role of cholesterol in disease in much greater detail."
This new understanding is leading physicians to re-think cholesterol control, he says. "We're renewing our focus on preventing disease, not just reducing numbers for numbers' sake. We are starting to see the reasons why many people with seemingly good cholesterol numbers still develop cardiovascular disease, and the opposite as well—why people with seemingly bad numbers often have no disease."
As these sub-particles within the larger cholesterol compounds are identified and better understood, new, targeted treatments, including new medications, will allow doctors to zero in on the specific factors that may be the culprits. "As we discover the actual pathways to atherosclerosis," the doctor says, "the next stage will be to customize treatments."
Thanks to another recent advance, there are now ways of measuring how much cholesterol an individual is producing as opposed to absorbing from food. "There has always been this 'nature vs. nurture' question," says Dr. Aronwald. "Cholesterol certainly has a genetic component, but there is also the 'nurture' element—what patients' lifestyles are doing to help or hurt lipid levels." Knowing which factor predominates in individual patients will also help doctors tailor treatment plans.
What else is on the horizon? A growing understanding of the role inflammation plays in cardiovascular disease, says the doctor. Either working in tandem with high cholesterol and other risk factors or acting on its own (the facts are still unclear), inflammation is now known to be strongly linked to heart disease— as well as other illnesses. A marker of inflammation called C-reactive protein, or CRP, can be found in blood tests, but as of now many insurance companies won't cover that test. Dr. Aronwald believes the test is important. "It can help quantify inflammation and let us treat it accordingly," he says. The current "gold standard" of inflammation treatment is daily low-dose aspirin therapy.
So—your take-home? Practice preventive medicine today by seeing your doctor regularly and taking good care of your body, and stay tuned for a future in which cholesterol management is much more sophisticated and effective. "I am excited that we are now measuring these new elements," says Dr. Aronwald. "And the next wave will be targeted therapies, or combination therapies, for those at risk for the disease."
Statins: to take or not to take?
Last fall, the American Heart Association and American College of Cardiology issued new cholesterol guidelines. They recommend statins for an estimated 33 million Americans without cardiovascular disease who have a 7.5 percent or higher risk for a heart attack or stroke within the next 10 years. That's a big jump from the 2002 federal cholesterol guidelines, which recommended only that people take a statin if their 10-year risk level exceeded 20 percent.
Some people questioned the recommendation and pointed out that statins do have known risks, which include liver, kidney and muscle dysfunction. But all medicines carry some element of risk, says Bruce Aronwald, D.O., a family physician at Saint Barnabas Medical Center. The key is to weigh the risks of statin medications against their benefits in consultation with your physician.
"We look at each patient as an individual, not as part of an overall recommendation guideline, because every individual has intrinsic and extrinsic components to his or her risk for disease," the doctor explains. "In our practice, we tend to be on the more aggressive side of cholesterol management, because we think the studies over the last 20-plus years suggest Bruce that we should be."