It is now common knowledge that the disease known as atherosclerosis (hardening of the arteries) is most often related at least in part to abnormalities of cholesterol or related substances in the blood such as triglycerides (fat). To the great benefit of millions of patients with atherosclerosis, very effective safe medications are now available to help lower cholesterol and triglycerides. Some basic understanding about cholesterol and triglycerides, commonly known as lipids, is useful for patients with a history of atherosclerotic disease of the blood vessels supplying the heart, the brain, the legs, or the kidneys. A very substantial reduction in complications such as heart attack and stroke can be accomplished by appropriate lipid management in these patients. Even patients without proven atherosclerosis may be recommended to take these medications if their risk of heart attack or stroke is deemed to be sufficiently high so that risk reduction is clearly indicated.

Cholesterol and triglycerides travel in the blood in the form of lipoproteins, complex molecules containing fat and proteins which are soluble in plasma. This is necessary since by themselves cholesterol and fats are not soluble and could not be transported to the tissues where they are needed without a special form of transport. In the early days of research on these substances it was found that different types of lipoproteins can be separated with a centrifuge based on different densities. Hence, you will see lab reports refer to HDL (high density lipoprotein cholesterol fraction), LDL (low density lipoprotein cholesterol fraction), and VLDL (low density lipoprotein cholesterol fraction). This latter fraction is mainly triglycerides, which is most often reported as a separate value. HDL cholesterol seems to be in a form that is available to be eliminated from the body and the higher HDL level, the more likely atherosclerosis will be controlled and complications such as heart attack will be prevented. For this reason, the HDL cholesterol has been called the “good cholesterol”, because it is good to have a high HDL level. On the other hand, LDL cholesterol is in a form that is available to be deposited into the tissues and directly contributes to the development and progression of atherosclerosis and its complications. LDL is often referred to as the “bad cholesterol”. Triglycerides, which are the fat component of lipids, are less important but do contribute to atherosclerosis and elevated triglyceride levels are usually associated with low HDL levels, which is bad. Very high triglyceride levels can cause other serious medical problems like inflammation of the pancreas, and often require treatment for this reason as well.

Basically, the strategy in dealing with lipids that require treatment is to try to get the LDL (bad) cholesterol level lower, the HDL (good) cholesterol level higher, and the triglycerides normal if possible. Diet and lifestyle are important! Smoking cigarettes or being overweight lowers the HDL cholesterol significantly. These things must be avoided if at all possible. Poorly controlled diabetes causes elevated triglycerides levels and this usually lowers the HDL. Regular exercise reduces body fat, elevates HDL cholesterol and usually improves triglycerides and LDL cholesterol levels. Dietary changes can markedly affect LDL cholesterol and triglycerides so diet is very important for patients with atherosclerosis. Restriction of dietary fat, particularly saturated fat is of paramount importance. The American Heart Association and almost any bookstore in Austin can provide ample detailed dietary instructions in this regard. The so called “Pritikin diet” is very close to optimal and books on this diet are widely available in stores also. The so-called Mediterranean diet (high in fish, fresh fruit and vegetables, pasta and olive oil or Canola oil) also merits serious consideration for individuals with atherosclerotic cardiovascular disease and problems with elevated cholesterol. This diet does not actually lower cholesterol, but seems to have a very significant benefit of preventing heart attacks through mechanisms that are not completely understood.

The question of alcohol and red wine consumption usually comes up in any discussion of dietary prevention of heart attacks. Regular, moderate alcohol consumption, particularly red wine, seems to elevate the HDL level, but it can certainly cause many other serious problems, including alcohol addiction, automobile accidents, behavioral and psychiatric problems, overweight, high blood pressure, and other complications. The usual recommendation for patients at risk for heart attack is that already existing, moderate alcohol consumption if well tolerated is not prohibited, as long as alcohol use is responsible and there are no other complications. However, if triglycerides are elevated or strength of the heart is weak, or the heart rhythm is unstable, regular alcohol consumption is to be discouraged. It needs to be made clear that patients who do not already use alcohol as an established lifestyle pattern are not recommended to start using it to improve a low HDL level. Weight reduction if overweight, being a non-smoker, regular aerobic exercise, and certain medications can be used when the HDL cholesterol is low. This subject has received increasing attention and emphasis in the most recent recommendations for treatment of elevated cholesterol and triglyceride levels.

The current recommendations for treatment goals for patients with coronary atherosclerosis or a risk of heart attack equal to such patients (including all diabetics, patients with peripheral vascular disease, and patients with carotid vascular disease) is to lower the LDL cholesterol below 100 mg/dl. This level is often not achieved or not maintained by dietary measures alone. Medications are therefore very important in the management of patients with lipid abnormalities. The class of medications known as “Statin” drugs inhibit an enzyme in the liver that is the rate limiting or rate setting step for manufacture of cholesterol. These medications are truly “miracle drugs” because their degree of effectiveness if remarkable and they are well tolerated by the great majority of patients. One of these medications will usually be utilized if the LDL cholesterol is elevated. Medications that lower triglycerides effectively are usually in the class of “Fibric acid derivatives”. These medications do not have a very powerful effect on LDL, but the HDL will often rise if the triglycerides fall, because of their inverse relationship. Niacin (a vitamin) in very high doses is the medication that is most effective at raising HDL cholesterol, but not all patients are able to take high doses of niacin due to the side effect of flushing. There are strategies to deal with these issues of side effects and they usually work well if the patient is determined to get the cholesterol problems corrected and therefore willing to make an effort. A newer medication, Zetia, which partially blocks cholesterol absorption in the intestinal tract is proving to be very useful, particularly when combined with other cholesterol lowering medications, and these combinations do not appear to have increased side effects.

Some other agents are sometimes useful for individual patients. For instance, the butter substitute “Benechol” lowers LDL cholesterol somewhat in most patients. Resin binding drugs that attach to cholesterol in the gastrointestinal tract and take it out of the body may be useful in lowering LDL cholesterol, but high doses are often poorly tolerated due to gastrointestinal side effects. Combinations of medications are often prescribed for patients in an attempt to successfully lower LDL, raise HDL, and normalize triglycerides. The possibility of side effect, the cost, and the complexity of monitoring all increase with combination therapy, but the beneficial effects in controlling atherosclerosis are definitely increased by this approach of using multiple medications when needed. It is well known that lipid altering medications can affect the liver and can cause muscle pains and sometimes inflammation in the muscles with muscle damage. Liver tests are always checked when these medications are started and may be rechecked from time to time. If they occur, unexplained, disturbing muscle pains, especially if accompanied by objective signs of muscle weakness, should be reported immediately to the prescribing physician by patients who are taking lipid altering medication. The medication(s) may sometimes be stopped briefly to see if the muscle symptoms will resolve.

Please be sure to bring your medication bottles with you for all visits to our offices. Tell the nurse when your medications are reviewed how you are actually taking the medication in each bottle. We have not found any other way to be sure we know what medications you are really getting. Our decisions and recommendations may be seriously flawed if the information we have is incorrect or incomplete.

Patients on lipid altering medication require periodic follow up and lab tests as specified by the prescribing physician. At the present time effective lipid management has the most powerful effect of any type of medication in preventing heart attacks and all their complications. It is extremely important that due attention is paid to this important aspect of overall patient management for all patients with atherosclerotic cardiovascular disease and / or high risk for heart attack based on risk factor assessment. Capital Cardiovascular Specialists takes great pride in making a sincere attempt to make sure that lipids are being managed optimally for our patients. May of the primary care physicians in the Austin area are also very well educated and skillful in this regard. If lipids are being managed by the primary care physician, questions regarding lipids should generally be directed to that physician’s office.