Tell Me What You Want

I am asking readers to tell me what you want.  Not in general, but at a health or wellness talk.  A few weeks ago I was asked to speak at a wellness seminar given at a company for its employees about heart health.  The talk was well received, and we had a good discussion after my presentation.

What struck me was how willing people were, in a room full of co-workers, to ask questions about their personal health.  In the office, we have safeguards to protect privacy at check-in, in the waiting room and at check out.  Yet in this conference room, with people they know listening, I was told about cholesterol results and other tests, treatments they were given, etc.  Granted, we were talking about heart disease, which may not seem as socially or professionally awkward as some other topics, but it still surprised me.

It also made me wonder – what did they want?  My professional interpretation and opinion of their situation, or validation that the choices they had made in their own care were “good choices”?

I did my best based on the information people gave me to address their concerns, while encouraging them to speak to their doctors.  Some had questions understanding what they were treating or how to interpret their results.  Others had decided to try a different therapy (often homeopathic) than what their doctor recommended and wanted my approval – so the answer to my initial question is “both”.

I found it to be a little uncomfortable being asked to approve someone’s decisions with limited information, especially if I didn’t “approve.”  However, the talk and Q&A are for the attendees, not me, so I did my best to give a recommendation and encourage discussion between the person and their doctor.

This is a copy of the talk I gave – I want to thank TheVisualMD for the image support in the talk.

My question to you – if you went to a talk like this what would you prefer?  A general Q&A or time at the end to make a mini-appointment to discuss your questions one on one with the speaker?  Tell me what you want!

The path to wellness begins with a proper diagnosis

Advanced Lipid Testing – when “bad cholesterol” isn’t good enough

In an earlier post, I reviewed the new ACC/AHA guidelines for treating cholesterol.  These guidelines recommend basing treatment solely on LDL-c or the “bad cholesterol”, treating when it is high but not to a specific target.  Over the last several decades, lowering levels of LDL-c has resulted in a decreased rate of heart disease that combined with advances in treatment has also reduced the death rate from heart disease.

Despite these advances, heart disease remains the number one killer of Americans.  A 2009 study from ULCA demonstrated that half of people who have heart attacks have relatively “normal” levels of LDL-c cholesterol.  What are we missing in these people?  Is their another marker we could measure to more accurately predict risk?  

What is Cholesterol testing?

Low Density Lipoprotein is the “sticky stuff” that clogs arteries.  Cholesterol is a carrier for the lipoproteins that circulate in our blood.  The more lipoproteins in you blood, the greater your risk for heart disease.  Historically we have used the measurement of LDL cholesterol to act as a surrogate measure of these sticky proteins because it was the best we had.  We have had a tremendous impact on heart disease by treating cholesterol.

The problem with LDL-c measurement is that it is a calculation based on certain assumptions about how the sticky proteins are distributed in the system.  The model breaks down when triglycerides (another component of a cholesterol panel) are elevated.  When this occurs, the sticky proteins are not distributed evenly and you have a lower level of LDL-c than the true level of sticky proteins that cause plaque.  The result is that the traditional LDL-c reading will underestimate the risk of heart disease – helping to account for the “half of heart attack victims with normal cholesterol.”

What other markers are there for lipid testing?

Many measurements have been evaluated to see if there are better predictors of heart disease than LDL-c.  3 of the most promising are Non-HDL-c, Apo-B and LDL particle number (LDL-p).  

Non-HDL-c is a calculation that simply subtracts the HDL-c level from the Total Cholesterol level in a standard lipid panel.  For those at highest risk of heart disease, a non-HDL-c level over 130mg/dl is associated with increased risk of heart disease regardless of what the usual LDL-c is.  The advantage of this reading is that it can be determined at no additional cost from a standard lipid panel.  Disadvantages are variability based on fasting state and that it may not predict how well medication is reducing risk.

Apo-B is a protein that is deposited in the walls of arteries to create plaque.  It is carried through the system by cholesterol.  The more Apo-B in your system the greater your risk of heart disease.  Each particle of low density lipoprotein contains 1 molecule of APO-B.  Studies have shown that Apo-B levels can remain elevated even in setting of “normal” cholesterol levels.

LDL-p directly measures the particles of low density lipoprotein that account for the risk of heart disease.  Studies have shown that LDL-p can be elevated even when cholesterol levels are normal.  Information presented at the most recent American Cardiology Conference demonstrated that treating patients to a normal LDL-p had a 22-25% reduction in heart attacks than those treated to traditional goal cholesterol values.

How does this affect my practice?

I see patients at increased risk of heart disease on a daily basis.  I generally order a traditional cholesterol panel on all patients.  When their history indicates an increased risk of heart disease – due to family history, diabetes, hypertension or obesity, I will order an LDL-p as well.  I will also order an LDL-p if their traditional cholesterol panel shows high triglycerides.  I find this test to be one of the easiest to interpret as there are direct values that correlate with risk.  It also does not require fasting – making it a very convenient test indeed!

So while not everyone needs to have their LDL-p measured, it is important not to simply accept a cholesterol reading at face value.  Like all tests, it needs to be interpreted in the setting of your individual risk factors and other medical conditions.  Knowing your real risk of heart disease is a necessary initial step towards improving your health!

The path to wellness begins with a proper diagnosis. 

The “new” cholesterol guidelines – what’s really the issue?

For decades people and doctors have been obsessed with cholesterol levels.  Books have been written, diets promoted, medications prescribed – all with the purpose of getting your cholesterol to “goal”.  You get your labs done and your doctor tells you your cholesterol is high.  You are instructed to eat a low-fat diet, exercise more and possibly start a medication.  Often you are not sure which numbers are high, or what they mean.  But you know that high cholesterol is a bad thing, and so you try to follow the doctor’s advice and lower your cholesterol.  
11/12/13 was a unique date – not only the second to last sequential month/day/year in our lifetimes; it is also the day the American College of Cardiology (ACC) and American Heart Association (AHA) released new guidelines for cholesterol management that recommend treating high cholesterol but not to any specific number.
This represents a change in over a decade of “goal oriented” recommendations which specified a level of bad cholesterol (LDL) to aim for, using multiple medications if needed to get there.
New Guidelines for Cholesterol:
  • Aim for cholesterol to be reduced by half
  • Only use a statin medication
  • Not necessary to add other medications if you don’t get quite there
Why were these changes recommended?
The theory behind the changes is that the guideline committee felt there wasn’t strong enough evidence supporting a specific target.  For example, if a person’s LDL cholesterol is reduced from 195 to 95, is there any real additional benefit in getting to the previous high risk goal of 70? Or is 95 good enough?
So what are the recommendations?
People are broken down into 2 risk groups in terms of deciding if a statin should be used
  1. High Risk:  people with a prior heart attack, bypass surgery, a stent or diabetes should take statins.  Statins are also recommended for those with very high LDL cholesterol (>190)
  2. Future Risk:  those whose 10 year risk of a heart attack is 7.5% or greater.  This number is calculated with a risk calculator that uses cholesterol, weight, blood pressure, smoking and other factors to come up with your number.
The High Risk group is not a  major change in terms of starting treatment.  The change is not recommending a target value for the LDL cholesterol.
The Future Risk group is different – the previous recommendations used a higher 10 year risk 15-20% before starting a statin.
Besides statin therapy, lifestyle changes are a cornerstone of the new recommendations:
  • No smoking
  • A health body weight
  • Exercise
  • A diet with lots of vegetables, fruits and lean protein
Controversy
Not all doctors agree that the 10-year risk is the best guide for starting treatment – why not lifetime risk?  There also have been questions about the risk calculator itself – the formula used appears to overestimate risk – including more people needing treatment than may truly benefit.  In addition, several of the members of the guideline committee quit due to disagreement on the direction the committee was going with their recommendations.  The remaining committee members only considered evidence from very specific types of trials, ignoring other trials that made compelling arguments but did not meet their standard of evidence.  The committee also chose not to include other markers of cardiovascular disease such as LDL particle number, Apolipoprotein B, PLAC testing and LDL particle size.
So how will this affect MY practice?
I think the guidelines are an opportunity to talk to people about their real diagnosis – their risk of cardiovascular disease.  As I have told many patients – to a certain extent, I don’t care what your cholesterol is, I care about you having a heart attack or stroke.  Cholesterol is a marker of how much artery clogging gunk is in your system.  There are several studies that show that the standard cholesterol profile underestimates cardiac risk.  I think that using the LDL particle number (LDL-p) is a better marker for assessing that risk.  If we reduce your LDL-p, your risk for cardiovascular disease goes down.  Statins are a tool (a very powerful one) to reduce cardiovascular disease risk.
I’m also not a fan of 10 year risk as a cutoff for starting treatment – I prefer lifetime risk, as the process that blocks your arteries is ongoing.  If we know 20 years before you have a heart attack that the risk is there, why wait until a heart attack is only 10 years away to start reducing risk?
How do I assess risk?
Risk can be estimated with a good history, a physical and testing.
History:
  • Prior heart attack, stroke or known cardiovascular disease?
  • Family history of heart attack or stroke – a male relative under age 55 or a female under age 65
  • Diabetes
  • High Blood Pressure
  • Smoking
Physical:
  • weight
  • waist size – belly weight is riskier than just being overweight
  • blood pressure
  • leg swelling
Diagnostic Testing
  • Cholesterol Assessment
    • there are several tests for this besides the standard cholesterol (called LDL-c) test which I will be reviewing in a future article in detail.  There have been several studies that show that other tests like LDL particle number (LDL-p) are better predictors of risk.
    • LDL cholesterol particle number (NMR Lipoprofile)
    • Apolipoprotein B (ApoB)
    • LP(a)
    • PLAC testing
    • Cholesterol particle size
  • C-reactive protein
  • Glucose
Once we put together your history, physical and test results we can have a discussion not about your LDL number, but your real diagnosis – your risk of cardiovascular disease.  The goal of that discussion is to reduce your risk of having a heart attack or stroke.
How can we reduce risk?
  • Blood pressure control
  • No smoking
  • Maintain a healthy body weight
  • Control diabetes
  • Being physically active
  • Control cholesterol
So the benefit of the new guidelines is they can inspire a conversation that leads to a proper diagnosis – not treating a number, but treating cardiovascular risk.

The path to Wellness begins with a proper Diagnosis