Cholesterol

The woman

The Arctic wind chilled the middle-aged African-American woman to the bone. A few brown leaves−residues of a colorful fall foliage− floated across her face. For a moment, she remembered the American poet laureate, Robert Frost’s quote about Nature:

 “Her early leaf's a flower;

But only so an hour.”

She felt her own good health vanishing as quickly as the colorful fall foliage. She was struggling to understand her high-density -lipoprotein (HDL) cholesterol (C) and low-density-lipoprotein-C (LDL-C) levels and how those high numbers were associated with her peripheral artery disease (PAD). The news that PAD increased her risk for a heart attack or stroke and the need to take a statin, came as the last straws. After losing her job, she had difficulty figuring out how she was going to pay for these medications and could not understand the doctor’s guidance. As a former biology teacher, she was also aware of the importance of cholesterol in steroid hormone synthesis and in the brain [1], as well as the post-marketing side-effects reported for statins. An analysis of evidence-based recommendations left her feeling swamped with reading too much information and she reached for her smartphone to call her neighbor – a patient advocate.

The patient advocate

The young man had substituted his dog-eared printed copy of Walt Whitman’s “Leaves of Grass” for reading several cholesterol-related references on his iPad. He was determined to help his friend, the African-American woman. She had been inundated with conflicting news stories about her risk for heart disease and the need to seek preventive treatment. He glanced at a British directory of websites which provided health and wellness information and was happy to see relevant information about cardiovascular risk assessments. How would this information compare with the latest guidelines issued jointly by the American Heart Association (AHA) and The American College of Cardiology (ACC)?

He flipped back to the source of her concern: the 2013 cardiovascular (CV) risk calculator − a companion tool to the 2013 ACC/AHA Guideline on the Assessment of CV Risk [2]. Doctors and patients could use this spreadsheet to estimate 10-year (for individuals 40 to 79 years old) and lifetime (for individuals 20 to 59 years old; most directly applicable to non-Hispanic whites) risks for atherosclerotic cardiovascular disease (ASCVD) i.e., coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke. He read the important caveat that estimates may represent under- and overestimates for persons of various ethnic groups and wandered if entering the required information (age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status) would yield a clinically meaningful number. A panel of experts had identified four major groups who could potentially benefit from statin therapy:  individuals 1) with predefined clinical ASCVD, 2) primary elevations of LDL–C >190 mg/dL, 3) diabetes aged 40 to 75 years with LDL– C 70 to189 mg/dL and without clinical ASCVD, or 4) without predefined clinical ASCVD or diabetes with LDL–C 70 to189 mg/dL and estimated 10-year ASCVD risk ≥7.5% [3].

 After pouring over all the information he could find about the cholesterol controversy, he summarized the information succinctly for the woman and advised her to consult with one or more physicians. He agreed with the opinion that prescribing statins was in the end a judgment call, except in the cases of high-risk individuals i.e., diabetics or patients who have already had a heart attack.

References

1.            Vance, J.E., H. Hayashi, and B. Karten, Cholesterol homeostasis in neurons and glial cells. Semin Cell Dev Biol, 2005. 16(2): p. 193-212.

2.            Goff, D.C., Jr., et al., 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 2013 [e-print].

3.            Stone, N.J., et al., 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 2013 [e-print].