Heart Health

Treatment of High Cholesterol

A new patient came to me after her father had suffered from a heart attack. Only after the heart attack did he find out he had hypercholesterolemia, or high cholesterol. Although my patient was a healthy 46-year-old woman, she also had high cholesterol, and she knew that hypercholesterolemia is a major risk factor for coronary artery disease (CAD)—the cause of heart attacks and angina. My patient's fasting lipid profile showed that she had a total cholesterol of 248 mg/ml, a low-density lipoprotein (LDL) of 162, a high-density lipoprotein (HDL) of 36, and a triglyceride level cholesterol of 250. She wanted to lower her cholesterol, but she had at least two other risk factors for CAD: she was post-menopausal and she smoked cigarettes.

Thus, in constructing a plan to reduce her cardiac risk, there was more to consider than just lowering her cholesterol down to a certain number. Let's look at the planning process in detail.

Assessing Cardiac Risk
A crucial part of the initial evaluation is assessing your risk factors for CAD, other than high cholesterol. The major risk factors are as follows:

• Age older than 45 for men and 55 for women
• Post-menopausal status (either natural or surgical) without hormone replacement therapy
• Family history of early atherosclerotic heart disease (early meaning younger than the age of 55 for male relatives or younger than 65 for female relatives)
• High blood pressure
• Diabetes
• Smoking
• Low HDL cholesterol (less than 35 mg/dl)

Establishing a Treatment Goal
Your target cholesterol level depends on several factors. The first is whether or not you already have coronary artery disease. My patient, whom I described earlier, does not have angina or any other symptoms of heart disease, so we are treating her hypercholesterolemia for primary prevention of CAD. Her father has already had a heart attack, so lowering his cholesterol is very important for secondary prevention—i.e., for preventing a subsequent heart attack. Second, your treatment goal depends on your number of CAD risk factors, as detailed below. Unfortunately, diabetes is such a strong risk factor for CAD that it requires the same aggressive treatment as those who have established heart disease.

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