Hyperlipidemia

with Robert Straub, M.D., Family Medicine, Columbia St. Mary’s

Posted: June 1, 2004

For the most part, said Dr. Robert Straub, a family medicine specialist with Columbia St. Mary’s, the words hyperlipidemia and high cholesterol can be used interchangeably. “It includes not only cholesterol,” he said, “but other lipids and triglycerides that are included in the overall classification of hyperlipidemia.”

Today, the link between high cholesterol and coronary artery disease, heart attacks and atherosclerosis is common knowledge. Television commercials tout the power of foods, exercise devices and other substances to lower cholesterol and decrease the risk for heart disease.

Robert Straub, M.D., Family Medicine, Columbia St. Mary's "The concept I try to get people to understand is that there are what can be thought of as good and bad cholesterol molecules circulating in the blood. The LDL cholesterol will deposit in the arteries, causing atherosclerosis (hardening of the arteries) and the HDL cholesterol helps reduce the deposits and decrease the atherosclerotic changes."

It was several decades ago that researchers conducting a long-term study of cardiovascular disease discovered the correlation. Since then, testing for hyperlipidemia has become a routine part of a physical examination.

“The concept I try to get people to understand is that there are what can be thought of as good and bad cholesterol molecules circulating in the blood. The LDL cholesterol will deposit in the arteries, causing atherosclerosis (hardening of the arteries) and the HDL cholesterol helps reduce the deposits and decrease the atherosclerotic changes,” Dr. Straub said.

“So there needs to be a certain balance between the ‘good’ cholesterol (the HDL) and the ‘bad’ cholesterol (the LDL) in order to prevent the progression of atherosclerosis and blockage of the arteries.”

Understanding the numbers
Testing for hyperlipidemia involves a blood test, preferably done while the patient is fasting. The sample is then analyzed to determine the types and levels of cholesterol and lipids in the bloodstream.

“The goal for most patients is a level of less than 200 for the total cholesterol and then less than 160 for LDL,” Dr. Straub said.

For patients with additional risk factors, the LDL goal is lower. Risk factors include age – 45 or older for men and 55 or older for women – a family history of premature heart disease, cigarette smoking, hypertension and diabetes.

Someone with two or more of these risk factors should keep their LDL cholesterol levels at 130 or below. Patients with pre-existing coronary disease, peripheral artery disease, carotid stenosis, aortic aneurysm, diabetes or an overall 10-year risk of greater than 20 percent of having a cardiac event (this is determined using a specific formula) don’t want to exceed LDL cholesterol levels of 100.

Triglyceride levels shouldn’t exceed 150, said Dr. Straub. These fats, which circulate in the bloodstream, also play a role in overall cardiovascular health. They’re also the main reason doctors prefer that a patient fast before coming in for a cholesterol test.

“With most lipid panels,” he said, “the LDL cholesterol level is calculated based upon the other levels, and the triglyceride level varies quite a bit based on what the patient has eaten that day.”

That’s important, because for every 100-point increase in triglycerides, the calculated LDL cholesterol level is artificially lowered by 20 points. So if your triglyceride level was 150 before breakfast, and 350 after lunch, you could end up with an inaccurate LDL cholesterol reading 40 points lower than the true LDL and a false sense of security about your heart health.

The first thing Dr. Straub recommends for his patients with high cholesterol is lifestyle modification. Smokers should quit. People should increase their exercise levels and modify their diets.

Diet recommendations
“I tell people they should increase their intake of fruits and vegetables and eat a diet higher in fiber,” he said. “Individuals need to decrease the intake of red meats and increase the intake of white meats and fish.”

Meats and fish should be broiled or baked, not fried. “I tell people that eating a piece of fried chicken is no better than eating the steak,” he said.

Regarding dairy products, Dr. Straub said butter and milk with a fat content of greater than 2 percent should be limited, as should margarine that isn’t specifically labeled as heart-healthy. One egg yolk a week is fine, if you like more than that, stick to whites-only.

Alcohol intake should be restricted to no more than one or two glasses per day. There may be a benefit to red wine, Dr. Straub said, but it’s not yet known whether it’s the alcohol, the particular grape, or some other factor.

Patients on the Atkins diet, he said, can remain on the diet if they don’t “go overboard” on the fried foods, red meats, bacon, egg yolks and butter.

Medications
For some patients, lifestyle modifications aren’t enough. Those in higher risk categories, or those for whom lifestyle modifications alone don’t work can take medications that help lower cholesterol and triglyceride levels.

The four main classes of medication used to treat hyperlipidemia are the statin medications, niacin, the fibrates and the cholesterol absorption inhibitors.

Some trade names of statin medications are Lipitor, Zocor, Pravachol, Lescol and Crestor. They work primarily to lower LDL cholesterol.

The second class is a common B vitamin, niacin. Niacin helps increase HDL cholesterol and is often used with a statin when exercise and a statin alone don’t increase HDL levels.

Fibrates, the third class, work primarily to lower the triglycerides.

The fourth class is the cholesterol absorption inhibitors (CAIs). A previous generation of cholesterol absorption inhibitors, the bile acid sequestrants, worked differently than the current CAIs. The newest of these, Zetia, decreases cholesterol levels by affecting its absorption from the intestinal system.

Patients on any of these medications are monitored every three to six months, both to ensure that the treatment is working, and to make sure there are no significant side effects.

Most patients who are on medication for hyperlipidemia are on statins; some are on a statin and sometimes one or two of the others. The most important consideration regarding combination medication, said Dr. Straub, is to make sure that the potential for drug interactions and negative side effects is kept to a minimum. That goes for patients taking medication for other conditions as well as those on combination treatment for treatment of hyperipidemia.

Some side effects may be uncomfortable, such as minor muscle pain. Others, such as rhabdomyolysis (a more significant muscle problem or myopathy) or liver problems, are more serious. But Dr. Straub emphasized that for most patients, the benefits far outweigh the potential risks and that far more people suffer complications from untreated hyperlipidemia than they do from treatment for the condition.

“As long as the patient and their physicians are aware of the risk and monitor for those,” he said, “the medications are very safe to use.”

We Have Answers Do you have medical questions or need help finding a doctor? The experts at Columbia St. Mary's and Advanced Healthcare can help. Click here.