Cholesterol Management Guide

How to Lower Your Cholesterol

Cholesterol helps your body build new cells, insulate nerves and produce hormones. Normally, the liver makes all the cholesterol the body needs. But cholesterol also enters your body from dietary sources, such as animal-based foods like milk, eggs and meat. Too much cholesterol in your body is a major risk factor for cardiovascular disease.

How Does High Cholesterol Cause Heart Disease?

When there is too much cholesterol in your blood, it builds up in the walls of your arteries. Over time, this buildup causes the arteries to harden -- a process called atherosclerosis. The arteries become narrowed and blood flow to the heart muscle is slowed down or blocked. The blood carries oxygen to the heart, and if enough blood and oxygen cannot reach your heart, you may suffer chest pain. If the blood supply to a portion of the heart is completely cut off by a blockage, the result is a heart attack.

There are two forms of cholesterol that most Americans are familiar with: Low-density lipoprotein (LDL or "bad" cholesterol) and high-density lipoprotein (HDL or "good" cholesterol.) These are the form in which cholesterol travels in the blood. LDLs have little protein and high levels of cholesterol and HDL has a lot of protein and very little cholesterol.

LDL is the main source of artery clogging plaque. HDL actually works to clear cholesterol from the blood.

Triglycerides are another fat in our bloodstream. Research is now showing that high levels of triglycerides is also linked to heart disease.

What Are the Symptoms of High Cholesterol?

High cholesterol itself does not cause any symptoms; so many people are unaware that their cholesterol levels are too high. Therefore, it is important to find out what your cholesterol numbers are because lowering cholesterol levels that are too high lessens the risk for developing heart disease and reduces the chance of a heart attack or dying of heart disease, even if you already have it.

What Cholesterol Numbers Should I Look For?

Everyone over the age of 20 should get their cholesterol levels measured at least once every 5 years. The test that is performed is a blood test called a lipoprotein profile. That includes:

• Total cholesterol level
• LDL (the "bad" cholesterol)
• HDL (the "good" cholesterol)
• Triglycerides

Here's how to interpret your cholesterol numbers:

Total Cholesterol	Category
Less than 200	Desirable
200 - 239	Borderline High
240 and above	High

LDL Cholesterol	LDL-Cholesterol Category
Less than 100	Optimal
100 - 129	Near optimal/above optimal
130 - 159	Borderline high
160 - 189	High
190 and above	Very high

HDL*	HDL-Cholesterol Category
60 or more	Desirable - helps to lower risk of heart disease
Less than 40	Major risk factor - increases the risk for developing heart disease

*HDL (good) cholesterol protects against heart disease, so for HDL, higher numbers are better.

Triglycerides	HDL-Cholesterol Category
Less than 150	Normal (desirable) heart disease
150-199	Borderline high
200 or more	High, may require treatment in some people

What Affects Cholesterol Levels?

A variety of factors can affect your cholesterol levels. They include:

• Diet. Saturated fat, trans fat, and cholesterol in the food you eat increase cholesterol levels. Reducing the amount of saturated fat and trans fats and cholesterol in your diet helps lower your blood cholesterol level.
• Weight. In addition to being a risk factor for heart disease, being overweight can also increase your cholesterol. Losing weight can help lower your LDL, total cholesterol levels, and triglyceride levels, as well as raise your HDL.
• Exercise. Regular exercise can lower LDL cholesterol and raise HDL cholesterol. You should try to be physically active for 30 minutes on most days.
• Age and Gender. As we get older, cholesterol levels rise. Before menopause, women tend to have lower total cholesterol levels than men of the same age. After menopause, however, women's LDL levels tend to rise.
• Heredity. Your genes partly determine how much cholesterol your body makes. High blood cholesterol can run in families.
• Medical conditions. Occasionally a medical condition may cause an elevation of cholesterol levels in the blood. These include hypothyroidism (an underactive thyroid gland), liver disease and kidney disease.
• Medications. Some medicines, like steroids and progestins may increase the "bad" cholesterol and decrease the "good" cholesterol.

How Is High Cholesterol Treated?

The main goal in lowering cholesterol is to lower your LDL and raise your HDL. To lower cholesterol, eat a heart-healthy diet, exercise regularly, and maintain a healthy weight. Some may also need to take cholesterol lowering medications.

Doctors determine your "goals" for lowering LDL based on the number of risk factors you have for heart disease.

Major risk factors include: age (men 45 yrs and older, women 55 years and older), cigarette smoking, hypertension, an HDL less than 40 mg/dL, family history of premature heart disease in a male first degree relative less than 55 years and female first degree relative less than 65 years of age.

• If you have 0-1 risk factor for heart disease, you are at low-to-moderate risk. Generally, lifestyle changes are effective in keeping the cholesterol in check.
• If you have 2 or more risk factors for heart disease, you are at moderate risk, depending on what heart disease risk factors you have. Sometimes your doctor will try lifestyle changes, but most of these people require cholesterol-lowering drugs or drugs to raise HDL.
• If you have known heart disease, diabetes or multiple risk factors, you are at high risk. These people require a combination of cholesterol-lowering drugs and lifestyle changes to control their cholesterol levels.

Goals for treatment are based on the revised guidelines from the Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program, Update, Circulation. 2004;110:227-239.

LDL cholesterol goals include the following:

• Category I, Highest Risk(ten-year risk greater than 20%*): your LDL goal is less than 100 mg/dL. For those with a very high risk (those who have had a recent heart attack, those with cardiovascular disease or peripheral artery disease combined with diabetes or poorly controlled risk factors, or those with metabolic syndrome), it may be most effective for the LDL goal to be less than 70 mg/dL.
• Category II, Next Highest Risk(ten-year risk 10-20%*): your LDL goal is less than 130 mg/dL. Your doctor may set your LDL goal at less than 100 mg/dl if your LDL is 100-129.
• Category III, Moderate Risk(ten-year risk less than 10%*): your LDL goal is less than 130 mg/dL. Your doctor may set your LDL goal at less than 100 mg/dl if your LDL is 100-129.
• Category IV, Low Risk(0-1 risk factor*): your LDL goal is less than 160 mg/dL.

*Risk categories are based on the Framingham Heart Study to estimate 10- year risk for coronary heart disease (myocardial infarction and coronary death). It is based on adults aged 20 and older who do not have heart disease or diabetes. The risk factors included in the Framingham calculation are age, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension, and cigarette smoking.

To reduce your risk for heart disease or keep it low, it is very important to:

• Control any other risk factors you may have, such as high blood pressure and smoking.
• Follow a low saturated fat, low cholesterol eating plan
• Maintain a desirable weight.
• Participate in regular physical activity.
• Begin medication therapy as directed by your physician.

What Drugs Are Used to Treat High Cholesterol?

Cholesterol-lowering drugs include:

• Statins
• Niacin
• Bile-acid resins
• Fibric acid derivatives

Cholesterol-lowering medicine is most effective when combined with a low-cholesterol diet and exercise program.

Statins
Statins block the production of cholesterol in the liver itself. They lower LDL, the "bad" cholesterol, and triglycerides and have a mild effect in raising HDL, the "good" cholesterol. These drugs are the first line of treatment for most people with high cholesterol. Side effects can include intestinal problems, liver damage, and in a few people, muscle tenderness or weakness.

Examples of statins include:

• Altocor
• Crestor
• Lipitor (atorvastatin)
• Lescol (Fluvastatin)
• Mevacor (lovastatin)
• Pravachol (pravastatin)
• Zocor (simvastatin)

Advicor is a combination of a statin and niacin (see below).

Caduet is a new drug that is a combination of a statin (Lipitor or atorvastatin) and a blood pressure-lowering drug called amlodipine(Norvasc).

Niacin
Niacin is a B-complex vitamin. It's found in food, but is also available at high doses by prescription. It lowers LDL cholesterol and raises HDL cholesterol. The main side effects are flushing, itching, tingling and headache, yet aspirin can reduce many of these symptoms. However speak with your doctor first. Niacin or nicotinic acid, includes the brand names Niacor, Niaspan, or Slo-niacin. Over-the-counter preparations include extended-release, timed-release, and controlled-release. Niacin found in dietary supplements should not be used to lower cholesterol. Your doctor or lipid specialist will let you know what type of niacin is best for you.

Bile Acid Sequestrants
These drugs work inside the intestine, where they bind to bile and prevent it from being reabsorbed into the circulatory system. Bile is made largely from cholesterol, so these drugs work by reducing the body's supply of cholesterol, thus lowering total and LDL cholesterol. The most common side effects are constipation, gas, and upset stomach. Examples of bile acid resins include:

• Questran and Questran Light (cholestyramine)
• Colestid (colestipol)
• WelChol (colesevelam)

Fibrates
Fibrates lower triglyceride levels and can increase HDL and lower LDL cholesterol. The mechanism of action is not clear but it is thought that fibrates enhance the breakdown of triglyceride-rich particles and decrease the secretion of certain lipoproteins. In addition, they induce the synthesis of HDL.

Examples of fibrates include:

• Tricor (fenofibrate)
• Lopid (gemfibrozil)
• Lofibra (fenofibrate)

Cholesterol absorption inhibitors
Zetia (ezetimibe) works to lower LDL by inhibiting the absorption of cholesterol in the intestines. Vytorin is a newer drug that is a combination of Zetia (ezetimibe) and a statin (simvastatin), and can decrease total and LDL cholesterol and raise HDL levels.

In some cases, patients may be prescribed more than one cholesterol-lowering drug to achieve the desired results.

What Are the Side Effects of Cholesterol-Lowering Drugs?

The side effects of cholesterol-lowering drugs include:

• Muscle aches*
• Abnormal liver function
• Allergic reaction (skin rashes)
• Heartburn
• Dizziness
• Abdominal pain
• Constipation
• Decreased sexual desire

*If you have muscle aches, call your doctor immediately. This could be a sign of a life-threatening condition.

Are There Foods or Other Drugs I Should Avoid While Taking Cholesterol-Lowering Medicine?

Ask your doctor about the other medications you are taking, including herbals and vitamins, and their impact on cholesterol-lowering medications. You should not drink grapefruit juice while taking cholesterol-lowering drugs, as it can interfere with the liver's ability to metabolize these medications.