Health Journey: What You Need to Know About Cholesterol

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Ashish Sarraju, MD:

Hello, everybody. My name is Ashish Sarraju. I'm a preventive cardiologist at the Cleveland Clinic on the Main Campus in Cleveland, Ohio. As a preventive cardiologist, my focus and my specialty are to help people address their risk factors to decrease their likelihood of either getting heart disease or if there is already some heart disease history to try to decrease the risk of future events. So as part of this, we discuss risk factors, lifestyle changes, medications and overall goals for every patient that we see. And the preventive cardiology clinic at the Cleveland Clinic is always accepting new patients who are interested in lowering their risk for heart disease. I wanted to take some time to answer some questions about cardiovascular disease prevention posed by our patients. Going through these questions one by one, I'm just going to read the question out loud, and then give you my sense of the answer or what patients should do to address that question.

So, the first topic or question from one of our patients was an overview of cholesterol values or when we test the cholesterol, we get a number of different tests: the total, the triglycerides, HDL, non-HDL, and several ratios as well as the LDL. And can we provide an overview of that? So that is a great question. When a cholesterol test is ordered, there are different lab values that you'll see as part of that test, and they include the total cholesterol, the LDL cholesterol, the triglycerides, the HDL cholesterol, and the non-HDL cholesterol, as well as several ratios including the total cholesterol to HDL ratio, and the LDL to HDL ratio is often reported as well. Now, how to interpret this is always a matter of nuance and it's always a matter of the context in which they're being interpreted in terms of your medical history, your family history, and what the goals of the visit are.

But historically, LDL cholesterol has been labeled bad cholesterol and HDL good cholesterol, although I would say that's pretty simplistic. But the thing to note about all of these is that when you get a cholesterol test, it's important to discuss with the doctor what a good cholesterol test looks like for you with your own medical history, with your own family history. Maybe it means keeping the LDL at a certain level. Maybe it means trying to get the triglycerides lower than they are. But the most important way to interpret this is to discuss it with your doctor.

We have a question here saying, why fasting? When will you be able to see a difference in values? I think that's a great question. So, these days, we don't necessarily need fasting cholesterol tests to assess someone's cholesterol levels. Non-fasting cholesterol tests can be very reliable in assessing the cholesterol values. Triglycerides and possibly LDL cholesterol have some variability between fasting and non-fasting tests. If your triglycerides, for example, are very high on a non-fasting test, then we would recommend a fasting test to get a better assessment of it. And barring those specific situations, I think the most important thing is to get the test. So non-fasting tests tend to be quite convenient. So, at a place that does non-fasting cholesterol tests, I think it's very reasonable to get those for convenience, and then do a fasting test if there are specific questions that remain unanswered.

What are the ways to lower cholesterol naturally and non-medically? Again, very common question that we get from our patients. In many ways, it depends on what aspect of your cholesterol test you're trying to address, is it triglycerides or LDL cholesterol, and what your own family and genetic history is. Because in some cases, if you have a family history of a very high LDL cholesterol, for example, as part of a condition called familial hypercholesterolemia, then your cholesterol levels may not decrease as much with non-medical measures because of the genetic predisposition. But that said, ways to lower cholesterol naturally include diet, especially trying to avoid saturated fats and making sure to incorporate fiber naturally, especially plant-based fiber into your diet, and focusing really on healthy unsaturated fats. Exercise is important, which can affect the HDL levels, but overall can decrease cardiovascular risk in general. Weight loss can be important. Especially for triglyceride levels, weight loss can really decrease them if they're elevated. And making sure to avoid smoking and making sure to, if you're drinking alcohol, drink it in moderation, are some of the natural ways to try to lower cholesterol.

Here we have a question about, what medications can we use to lower cholesterol and how are they different? That's a great question. Again, there are many medications that we can use to lower cholesterol. Of these, statins are perhaps the most prescribed medications. We also have other medications that are either pills or injectables. The pills include medication such as ezetimibe or Zetia, bempedoic acid, bile acid resins, which we don't use as much anymore, and we have injectables called PCSK9 inhibitors such as Repatha or Praluent, as well as a newer medication called inclisiran. So really, the range of medications that we can use to lower cholesterol is quite wide. In addition to this, for triglycerides specifically, there are certain medications like fibrates, which can lower it, as well as prescription trend, the fish oil, so to speak, for certain patients has been prescribed to lower triglycerides as well.

They're all different in terms of why they are used. And again, they depend entirely on your medical history and your family history and what you and your doctor are trying to achieve with your cholesterol level and what your goal is. They all act on different parts of the cholesterol metabolism or clearance pathways or affect cholesterol absorption from the intestines. Thus, they all have different side effect profiles and different ways that they're metabolized in the body. So really, the best way to try to get at which agent is the best for you is to talk to your doctor or come to a preventive cardiology clinic to talk through your history and your family history, get a full assessment, get your cholesterol checked, and then make a decision on whether one of these agents is a good fit for you.

Here we have a question, can you reverse plaque buildup or only prevent further buildup? Very common question that we get. And really, the overwhelming amount of evidence that we have is that our best chance to reverse plaque that's already there is to keep our LDL cholesterol very, very low. Keeping the LDL cholesterol very, very low in prior studies, including many that were led here in the preventive cardiology section at the Cleveland Clinic, has been shown to be related to decreasing the plaque burden in the arteries. So, in addition to preventing further buildup by controlling all your heart disease risk factors, there is a possibility of plaque reversal that seems to exist when your LDL cholesterol is reduced to very low levels in prior studies.

What are the chances I will get clogged arteries again if I already have two stents? That's a great question. Again, something that I would really recommend discussing with your doctor, but this again depends on your family history as well as how well your risk factors are controlled. So really, I often talk about this as stacking the odds in your favor. So the best way, if you already have two stents, to stack the odds in your favor of preventing clogged arteries or issues with them is to aggressively control all the risk factors, aggressively control your lifestyle and make sure you're on the right medications, make sure you're hitting all the targets that are necessary across all risk factors, and then of course, talk to your doctor to make sure that everything is being addressed.

All right. Well, those were some of the many questions we had regarding cardiovascular disease prevention. Thank you very much for the opportunity to answer those questions. And if there are any outstanding questions or you'd like a more personalized look at your own profile, or you just want to seek the opinion of a preventive cardiologist to assess your current status, our preventive cardiology clinic at the Cleveland Clinic would be more than happy to do that for you. So please don't hesitate to give us a call and come to see us. With that, I hope you all have a great day.

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