A better way than standard cholesterol to measure cardiac risk

If a patient has high cholesterol, they’ve likely been urged by a doctor to start taking statins, or at least cautioned that they will be prescribed if their cholesterol increases any further. This is no surprise, as statins are the go-to drug that most physicians rely on to lower cholesterol. Statins do indeed lower cholesterol for most people, and high cholesterol can be dangerous, increasing the risk of atherosclerosis, which in turn increases the risk of heart disease, heart attack, and stroke.  Statins have no doubt helped millions of people- but sometimes at a price.

Doctors are sometimes quick to prescribe statins even when there is a low to moderate risk of cardiovascular risk, taking a “better safe than sorry approach”. The problem is that many people have at least some sort of side effect from statins, ranging from dizziness and muscle pain to increased blood sugar and neurological issues like sexual dysfunction and memory loss. Aside from the real damage this may cause, the psychological impact that these side effects may have on someone with a low to moderate risk of cardiovascular problems may cause them to give up statins altogether and resist using them again even if their cardiovascular risk increases. 

Statins are probably prescribed too often, and without considering more natural interventions like exercise, modifying the diet, and supplementing with omega-3 fatty acids from fish oil.

“The current American College of Cardiology guidelines for statin use emphasize collaborative decision-making between providers and patients,” Tomas Ayala, MD, FAAC, a cardiologist at Mercy Medical Center in Baltimore, Maryland, told Healthline.“In general, statins are not recommended for low-risk patients. For patients at high risk… statins are recommended for primary prevention of cardiac events. For those of immediate risk, statins are recommended only if the patient also has a high-risk illness, such as diabetes, peripheral vascular disease, or cerebrovascular disease.” (Tony Hicks, Healthline, Oct 19, 2019).

So, current standards are to consult with the patient and they are not recommended for low-risk patients. Some physicians may skip the discussion of statin side effects and alternatives with their patients and jump straight to writing a prescription for them. In addition, there is some question about how much cholesterol is to blame for eventual cardiac events: 

“A new national study has shown that nearly 75 percent of patients hospitalized for a heart attack had cholesterol levels that would indicate they were not at high risk for a cardiovascular event, based on current national cholesterol guidelines.” (Science Daily, Jan 13, 2009)

That same study, out of UCLA,  did point out that very high levels of cholesterol still correlated with heart attacks, but did not control for other things that can also contribute. The point is that other factors can be equally as important, if not more important than normally measured cholesterol. A good example is oxidized LDL. Oxidized LDL cholesterol is made in the body when low-density lipoprotein (LDL), sometimes called “bad” cholesterol, goes through a chemical reaction with free radicals (unstable molecules made during normal cell metabolism).  Oxidized LDL cholesterol can cause inflammation in the arteries, leading to the formation of plaques. Over time, fat, cholesterol, and other substances build up in the walls of the arteries, causing the plaques to grow. Plaque buildup can partially or completely block blood flow within an artery, increasing a person’s risk for coronary heart disease, peripheral vascular disease, cerebrovascular disease, stroke, and heart attack. 

Why is oxidized LDL relevant to the discussion over the effectiveness of statins? First, because oxidized LDL is likely a better predictor of cardiac events than just cholesterol (see this study for instance), and second because statins can decrease levels of coenzyme Q10 in the body (Qu H, et al, European Journal of Medical Research. 2018). CoQ10 is fundamental to the production of cellular energy in the mitochondria and is a powerful antioxidant. Its ability to destroy free radicals means that your CoQ10 levels can have a profound effect on cardiac health. This means that for some people, not only might they have a lesser risk for heart attack or stroke, but if they are prescribed statins, their risk factors may actually go up.

Again, statins may be essential for some patients, but they may very well be overprescribed, can cause side effects (some quite severe), and should be reserved for those with higher cholesterol levels. They also shouldn’t be the front-line defense against cholesterol (or more accurately, cardiac health). A more mediated, reasonable, and natural approach may be warranted, consisting of shifting to a more heart-healthy diet (the Mediterranean diet is a good example), introducing or improving a patient’s exercise regime, and having them take at least a daily dose of omega-3 fatty acids from fish oil, and possibly introducing other botanical supplements that may lower cholesterol and improve other aspects of cardiac risk factors. 

Of course, not every patient may respond to alternative approaches, but those who do can avoid the side effects of statins and may be convinced to stick with them after failing with alternative approaches if deemed necessary. Concurrently, patients could be tested for Oxidized-LDL. Precision Point Diagnostics offers oxLDL standalone or with lipids. Oxidized LDL with Lipids Profile gives oxLDL with total cholesterol, LDL, high-density lipoprotein (HDL), very low-density lipoprotein (VLDL), and triglycerides, and calculates an oxLDL:HDL ratio. A high oxLDL:HDL Ratio did a better job than traditional lipid markers when discriminating between patients with coronary artery disease and healthy subjects. 

“Circulating OxLDL was found to be associated with all stages of atherosclerosis, from early atherogenesis to hypertension, coronary and peripheral arterial disease, acute coronary syndromes and ischemic cerebral infarction.” (Nina Johnston, et al, Am J Cardiol. 2006 Mar)

In fact, “Oxidized LDL (oxLDL) exacerbates the atherosclerosis process by triggering pro-oxidant and pro-inflammatory pathways that lead to plaque instability through mechanisms independent of LDL” (Elena Rodríguez-Sánchez, et al, Antioxidants (Basel), 2020 Dec). This means that oxLDL testing is complementary to LDL testing, and seeing the results of both tests together, particularly when combined with looking at the oxLDL:HDL ratio, not only gives much greater insight into the cardiovascular risk factors of your patients but more accurately could categorize patients who are truly candidates for statin therapy, thereby more closely following the intent behind the guidelines from the American College of Cardiology.