1. Understanding and Controlling Cholesterol
MKMG
MOUNT KISCO MEDICAL GROUP
Michael S.Wein, MD
Katonah Office
(914)

2. Disclaimers, disclosures, conflicts of interest, etc…
Absolutely none

3. Tonight’s theme:
Maximal treatment of high blood pressure and high cholesterol, combined with smoking cessation, if necessary, prevents strokes and mini-strokes, and thus prevents multi-infarct dementia.

4. Dementia Alzheimer’s Disease (60%-80%)
Vascular “multi-infarct” (20%-35%)
Parkinson’s Disease (Lewy Body) (5%)
Infectious
Syphilis, AIDS, Creutzfeldt-Jacob, Lyme
Rare causes
Pick’s Disease, Huntington’s
“Reversible” causes (10%)
-- B12 deficiency, hypothyroidism, Syphilis, Lyme, NPH, sub-dural hematoma

5. Why it’s so important to control your cholesterol
Good quality evidence links elevated cholesterol with:
Coronary heart disease (atherosclerosis, heart attack, congestive heart failure)
Stroke, TIAs,  multi-infarct dementia
Kidney disease
Peripheral vascular disease
Carotid artery disease

6. Why it’s so important to control your cholesterol
There is a continuous, graded relationship between total cholesterol and coronary heart risk.
4x risk
½x risk

7. Why it’s so important to control your cholesterol
A meta-analysis of 38 clinical trials found that for every 10% decrease in LDL cholesterol, there is an 11% reduction in total mortality*
*Circulation 1998 Mar 17;97(10):

8. Understanding the numbers….

9. Understanding the numbers…
Cholesterol is insoluble in blood. It needs carriers called lipoproteins to transport it throughout the body. These lipoproteins are what we measure.
LDL: The “bad” cholesterol
HDL: The “good” cholesterol
Triglycerides: Fat particles in blood
This is what
matters most

10. LDL – The “Bad” Cholesterol
LDL Cholesterol Levels
190 mg/dL and above -Very High
160 to 189 mg/dL - High
130 to 159 mg/dL - Borderline High
100 to 129 mg/dL - Near Optimal
Less than 100 mg/dL – Optimal
Less than 70 mg/dL – Very Optimal
If we wanted everyone to have “optimal” cholesterol, almost
all of us would be on medication.
Instead, we look at all the other risk factors, and personalize the
goal to the individual.

11. HDL - The “Good” Cholesterol
The higher your HDL, the lower your cardiac risk.
Greater than 60 mg/dL - Optimal
40 to 60 mg/dL - Normal
30 to 40 mg/dL – Low
Less than 30 mg/dL – Very low
HDL has anti-atherogenic properties due to reverse cholesterol transport, antioxidation, blood vessel protection

12. Triglycerides – “Fats”
Elevated triglycerides are associated with increased cardiovascular risk; however the strength of this association is not as clear.
Must be measured after minimum 8-hour fast
Greater than 500 mg/dL -- Very high
200 to 499 mg/dL -- High
150 to 199 mg/dL -- Borderline
Less than 150 mg/dL -- Normal
Very high triglycerides can cause pancreatitis

13. Understanding the numbers…
Total cholesterol = LDL + HDL + 1/5 triglycerides
Patient A
Total
LDL
HDL -- 26
Trig
Patient B
Total
LDL
HDL -- 96
Trig
Take home point: “Total cholesterol” can be very
misleading; pay attention to what makes up the total

14. Treatment of high cholesterol
Lifestyle modification
Diet, exercise, weight loss
Medications
Statins should be first-line for almost everyone
Fibrates, Niacin, Fish oils, Zetia/Vytorin
Herbals?

15. Diet and Lifestyle

16. Diet Use common sense! Portion size and weight loss is key
Low saturated fat; low trans-fat (less than 7% of total calories should be from saturated fat)
Low cholesterol (less than 200mg chol/day)
One Egg McMuffin 260mg cholesterol
One McDonalds Deluxe Breakfast 575mg chol
Ask for referral to a dietician

17. Dietary changes Emphasize Avoid Colorful fruits and vegetables
Whole grains (wheat, oats, barley)
Lean meats and beans
Omega 3s (fish, plant sources
Soy, nuts
Balanced diet, portion control
Avoid
Fried foods
Saturated fats
Trans fats
Simple sugars
Cheese, egg yolks, beef, pork, poultry, shrimp in moderation
Fad diets

18. Exercise and weight loss
Goal of a minimum of 20 minutes of aerobic exercise, at least three days per week.
This is one of the most effective ways to raise HDL.

19. Case Study
19-year-old college student saw me for a physical. Height 5’10”; Weight 270 lbs.
Total
LDL
HDL -- 38
Trig – 185
Glucose – 124
(Weight 270 lbs)
June 11, 2008
Total
LDL -- 92
HDL -- 64
Trig – 47
Glucose – 84
(Weight 190 lbs)
October 8, 2008
80 lb
wt loss

20. Medication Treatment

21. Medication Treatment - Statins
Statin drugs should be the cornerstone of medication treatment for virtually all patients with elevated cholesterol.
Statins are the only class of drugs to demonstrate clear improvement in overall mortality in primary and secondary prevention of coronary heart disease.

22. Medication Treatment - Statins
The clear benefits of statins have been demonstrated repeatedly in multiple well-controlled randomized clinical trials.
There are more quality studies showing safety and clear benefits of statin drugs, than with all other classes of cholesterol lowering drugs combined.

23. Medication Treatment - Statins
LDL: The “bad” cholesterol
HDL: The “good” cholesterol
Triglycerides: Fat particles in blood
This is what
matters most
Decrease LDL by 20-60%!
Minimal increase in HDL (up to 10%)
Modest improvement in triglycerides (15-35%)
Statins:

24. Statins Lovastatin (generic for Mevacor) -1987
$4/month at Target/ Walmart
Lescol XL (fluvastatin) no generic available
Pravastatin (generic for Pravacol) -1991
Simvastatin (generic for Zocor)
Lipitor (atorvastatin) -no generic available
Crestor (rosuvastatin) -no generic available
Least
potent
Most
potent

25. Other Medications Gut absorption inhibitors Ezetimibe (Zetia)
Moderate LDL reduction (≈ 20%)
No effect on HDL
No effect on triglycerides
Vytorin (simvastatin plus ezetimibe)
Recent study (ENHANCE) showed no clinical benefit to
ezetimibe plus simvastatin, compared to simvastatin alone

26. Other Medications Fibrates Gemfibrozil (Lopid)
Fenofibrate (Tricor, Antara, Lofibra)
Minimal LDL reduction (≈ 10%)
Modest HDL improvement (up to 25%)
Best for triglyceride reduction (up to 50%)

27. Other Medications Niacin Limited by tolerability (flushing)
Niaspan, Slo-Niacin
Minimal LDL reduction (≈ 15%)
Modest HDL improvement (15-35%)
Modest triglyceride reduction (25- 30%)
Limited by tolerability (flushing)

28. Other Medications Fish Oils (Omega 3’s) Lovasa (previously Omacor)
Many OTC versions available
No LDL reduction
Minimal HDL improvement (3%)
Moderate triglyceride reduction (up to 50%)
Limited by GI side effects (oily stool)

29. Herbals and Alternative Treatments
Red Yeast Rice
Used in Chinese medicine to
remove “blood blockages” dating
back to Tang Dynasty (800AD)
May lower LDL ≈ 20%
Active ingredient is lovastatin.
Banned for sale in US by FDA, but may find it in Asian markets, internet, etc.
Problems with purity, contaminants, lack of standardization.

30. Herbals and Alternative Treatments
Plant Sterols and Stanols
Nature Made “Cholest-off”
Many other products such as Promise-Active spread, Promise-Active supershots, Benecol, Minute Maid Heart-Wise, Rice Dream Heart-Wise beverages
May reduce LDL slightly by inhibiting cholesterol absorption
There are NO clinical studies showing any benefit
A study in mice showed harm

31. Herbals and Alternative Treatments
Soy (isoflavones)
Has estrogen-like properties.
Initial studies suggested benefit, but a more recent systematic review showed only minimal benefit (3% LDL reduction) from large quantities of soy.
Feel free to substitute soy products for animal-derived products because they are low in saturated fat, high unsaturated fat, high fiber.
But, don’t take soy with the intention that it will lower your cholesterol.

32. Herbals and Alternative Treatments
Green Tea Extract
A small randomized controlled trial showed a statistically significant benefit, ≈10% LDL reduction
Garlic
Recent large well-controlled trial showed no benefit
Fiber (psyllium, oats, etc.)
Recent randomized controlled study showed statistically significant LDL reduction (≈10%)
AHA recommends high fiber diet as “optional dietary strategy to lower cholesterol”

33. MOUNT KISCO MEDICAL GROUP
MKMG
MOUNT KISCO MEDICAL GROUP
Michael S.Wein, MD
Katonah Office
(914)