For generations, physicians have pursued the reduction of cholesterol as the centerpiece of the fight against heart disease. This was intensified with the release of a clinical trial called PROVE IT in 2005, which showed a reduction in complications at 30 days in a group of patients who were hospitalized with a heart attack and who received a high dose of a statin (Lipitor) versus another group of similar patients who received a standard dose of a less powerful statin (Pravachol). There was a huge reduction of the low density lipoprotein (LDL), the so called “bad cholesterol” in the Lipitor group. The mantra became lower is better.
But this is folly. The fact is that about half of all patients who present to the hospital with a heart attack have normal or near normal cholesterol (and LDL) levels.
An interesting perspective was raised in another trial named JUPITER in 2009. That study showed that treatment with Crestor (another statin) resulted in significant reduction in cardiovascular events in apparently healthy men and women who had just mildly elevated LDL but elevated CRP (C-reactive protein), an indicator of inflammation.
The new cholesterol treatment guidelines have expanded the use of statins in primary prevention (patients without known heart disease).
This is short sighted. Cholesterol should not be viewed as “bad”. Cholesterol plays a critical role in our hormone synthesis, in the protection of our neurons (brain cells), in our immune protection and a multitude of other functions. Dr David Perlmutter’s book , Grain Brain documents the previously unheralded relationship between cognitive impairment (dementia) and lower cholesterol levels. So what should we do?
The standard cholesterol (lipid) test should be thrown out. Studies have shown that inflammation is the key mechanism in all diseases. The LDL that becomes deformed or oxidized (rusted) is the initiating event in the inflammatory cascade that leads to the plaque in the blood vessel and eventual rupture (heart attack). Another factor is the size of the LDL particles. The small dense particles are the ones that get through the inner lining of the blood vessels and begin the inflammation process. The higher the number of the LDL particle counts and the smaller the size of the LDL particles correlate with a higher cardiovascular risk. To make things even worse, there is no correlation between the LDL size and particle counts on the one hand, and the value of the total cholesterol and LDL in a standard panel on the other. The newer, expanded panel now reports the size and particle numbers, and in some cases the oxidized LDL. The truly high risk group shows derangement in these measurements.
This is the group that deserves the aggressive lifestyle intervention from a Functional Medicine perspective. It is the group that may benefit from the prudent use of targeted statin therapy.