Cholesterol and Your Heart: A Deep Dive Beyond the Basics

This is a part 4 of our discussion about what we can do to lower the risk of heart disease. If you have not read the previous posts, you can find them here - Part 1, Part 2, and Part 3. Today we will talk about cholesterol.

You've probably heard that high cholesterol is bad for your heart. But do you know why? And did you know that the story of cholesterol and heart disease is more complex than just "high cholesterol = bad"? Let's break it down in a way that's easy to understand and explore some of the latest thinking in heart health.

Cholesterol: What is it, and Why Do We Need It?

Cholesterol is a waxy, fat-like substance that's essential for our bodies to function properly. It's a building block for cell membranes, hormones (like estrogen and testosterone), and vitamin D. Our bodies are pretty amazing – they can make all the cholesterol we need! This is called endogenous cholesterol production, and it mainly happens in the liver.

Dietary Cholesterol: Does it Matter?

For a long time, we were told to avoid foods high in cholesterol, like eggs and shrimp. The thinking was that eating cholesterol would raise our blood cholesterol levels. We now know it's a bit more complicated than that. Only about 20-25% of the cholesterol in your bloodstream comes from the food you eat. Some people are more sensitive to dietary cholesterol than others. The rest of the cholesterol is made by your liver. How much cholesterol is produced inside the body is controlled, to a significant degree, by our genes.

The Cholesterol-Heart Disease Connection: It's More Than Just "High" or "Low"

When we talk about cholesterol and heart disease, we often focus on cholesterol build up in the walls of your arteries, forming plaque. This plaque can narrow the arteries, reducing blood flow (a condition called atherosclerosis), and increase the risk of heart attacks and strokes.

But here's the crucial part: cholesterol's impact depends not just on its quantity, but also on its movement through the blood and other factors affecting blood vessels. Cholesterol doesn't dissolve in water, so it travels through our bloodstream inside particles made of protein and other elements. Let's say a person has 200 units of cholesterol in their blood. Whether this cholesterol travels in two large container ships (100 units of cholesterol in each) or 200 small boats (1 unit of cholesterol in each) matters. The small boats are much more likely to sneak inside blood vessel walls and contribute to cholesterol plaque buildup, especially if these walls are already compromised by high blood pressure, high blood sugar, smoking, or chronic inflammation from conditions like obesity, gum infection, rheumatoid arthritis, and many others.

A New Focus: Particle Number and Inflammation

More and more, doctors are looking beyond just cholesterol levels. They're measuring things like:

ApoB: A protein found on cholesterol-carrying particles. The higher ApoB number, the more small cholesterol-carrying boats you have in your blood.
LDL-P: A direct measure of the number of LDL-cholesterol carrying particles.
hs-CRP: A marker of inflammation in the body.

These markers can provide a more accurate picture of your heart disease risk, even if your cholesterol levels appear "normal."

Treating High Cholesterol: A Multifaceted Approach

The goal of cholesterol treatment is to reduce your risk of heart disease. Treatment plans are tailored to each individual but generally involve a combination of:

1. Lifestyle Changes:

Diet: The Mediterranean diet, rich in fruits, vegetables, whole grains, legumes, and healthy fats, is a great example of a heart-healthy eating pattern. Limiting saturated and trans fats is also important.
Exercise: Aim for at least 150 minutes of moderate-intensity exercise per week.
Weight Management: Losing weight may improve your cholesterol levels.
Quit Smoking: Smoking damages blood vessels and increases the risk of heart disease.

2. Medications:

Statins: These commonly prescribed cholesterol-lowering drugs block an enzyme needed to produce cholesterol, reducing blood cholesterol by 25-60%. They lower the risk of heart attack, stroke, decrease the need for procedures like angioplasty and bypass surgery, and decrease the risk of dying from cardiovascular causes.
Ezetimibe (Zetia): This medication functions by inhibiting the absorption of cholesterol from food and bile in the small intestine. On its own, ezetimibe reduces cholesterol by approximately 18-25%. However, when paired with a statin, the effects are cumulative, resulting in a more significant overall decrease.
Bempedoic Acid (Nexletol): This newer medication functions similarly to statins but targets a different stage in the cholesterol production pathway. Bempedoic acid is a "prodrug," meaning it is inactive when ingested and becomes active only in the liver. Consequently, bempedoic acid mainly inhibits cholesterol production in the liver with minimal impact on other tissues. Due to this specific action, muscle-related side effects are less frequent with bempedoic acid compared to statins. However, in rare cases, bempedoic acid may affect tendons and can increase uric acid levels in the blood. This rise in uric acid makes it less suitable for individuals with a history of gout. Bempedoic acid is often prescribed for those who cannot tolerate statins or require additional cholesterol reduction. When used alone, bempedoic acid reduces LDL cholesterol by about 15-25%. Like ezetimibe, its effectiveness is enhanced when combined with a statin. There is also a combination pill that includes both bempedoic acid and ezetimibe, capable of lowering cholesterol by about 38%.
PCSK9 Inhibitors (Repatha, Praluent): These are injectable medications that need to be self-administered every two to four weeks. They work by helping the liver remove more cholesterol from the blood, dramatically lowering cholesterol blood levels by 50-70%.

3. Supplements:

Fiber: Soluble fiber, found in oats, beans, and psyllium, can help lower LDL cholesterol.
Red yeast rice: Contains small amount of naturally occurring statins that may lower LDL cholesterol.
Omega-3 fatty acids: May help lower triglycerides (another type of fat in the blood) and have anti-inflammatory effects.

Important Note: Always talk to your doctor before starting any new supplements, especially if you're taking other medications.

The Bottom Line

Understanding your cholesterol and heart disease risk is a journey. It's about more than just a single number on a lab test. By working with your doctor, adopting a heart-healthy lifestyle, and considering medication if needed, you can take control of your heart health and live a longer, healthier life.

If you'd like to discuss your personal situation and receive individualized advice, schedule an appointment with the Institute for Diabetes, Endocrinology, Adiposity, and Longevity today.

Till next time,

Dr. Koren

DISCLAIMER: The content on this webpage is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor or qualified healthcare provider. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.