High cholesterol is easy to underestimate because it does not cause any symptoms for a long time. We can live with him for years and not know it. Until it's too late. That is why it is so important to test cholesterol levels, especially LDL, at every possible opportunity - says prof. dr hab. n. med. Maciej Banach, cardiologist, head of the Department of Preventive Cardiology and Lipidology, Medical University of Łódź, chairman of the Polish Lipidological Society.
Professor, LDL cholesterol is sometimes called the silent killer of Poles. How much truth is there in this saying?
Unfortunately, a lot. If we take into account, for example, the study that we published last year, based on the global register of the Global Burden of Disease, it turns out that cardiovascular diseases are the biggest killer in the world, responsible for 40-50 percent. deaths.
Statistics show that 75 percent. of these deaths were due to cardiovascular diseases of atherosclerotic origin. Speaking of atherosclerosis, it is worth realizing that cholesterol is the key element of the atherosclerotic plaque. So he is definitely a silent killer, not only of Poles.
And why "silent"?
Because you can live with very high levels of LDL cholesterol for years, and over time, you won't get any symptom to suggest it. It can therefore be said that it is the most insidious disease factor in cardiology. I remember that when I was still a young doctor, we often said that hypertension was such a silent killer. In discussions with patients, we strongly emphasized the need to pay attention to specific symptoms such as headache, palpitations, facial flushing and general malaise - and advised that they always take their blood pressure when this happens.
There are no such symptoms in the case of high cholesterol. And if there is shortness of breath, decreased exercise tolerance, chest pains or pain in the limbs associated with peripheral arterial disease, it is a signal that atherosclerosis is already very advanced. That is why it is so important to regularly, at every possible opportunity, measure cholesterol levels, especially LDL cholesterol, because it is very predictive in terms of various complications of the disease.cardiovascular disease and its consequences.
Why is atherosclerosis so dangerous?
Atherosclerosis is a chronic inflammatory disease of the arteries. When inflammatory cells and cholesterol begin to build up in their walls, plaque begins to form and the blood flow through these vessels becomes increasingly disrupted. If the patient is left untreated, the plaque becomes thicker and thicker, causing the artery to narrow, or even close, sooner or later.
The place to which the blood supplies this vessel is ischemic then, which may result in myocardial infarction, stroke, critical ischemia of the lower limbs. If a young person has a heart attack who does not develop collateral circulation as a result of the occlusion of the vessel lumen, which would allow for a replacement blood supply to the organ in question, he or she may be fatal. On the other hand, in the elderly, a heart attack often has serious complications, for example, it may lead to heart failure.
In Poland, we already have almost one and a half million people with heart failure. Therefore, at every stage, we should do everything to identify lipid disorders early and treat them early, because if we treat them properly, intensively, lowering the level of LDL cholesterol significantly, we achieve good results.
We have a rule that the lower the better and the sooner the better - that is, the lower the concentration of LDL cholesterol and the sooner this is achieved, the greater the benefits. But not only that: the longer we stay for therapeutic purposes, the better. This may result in regression, in other words, a reduction in the volume of the atherosclerotic plaque and the recession of the atherosclerosis. Studies show that at least five years on a therapeutic target reduces the risk of any cardiovascular event by 25%.
Over the years, the biggest mistake doctors made was that they neglected the elevated LDL cholesterol in their patients, telling them not to worry and prescribing them a diet rather than medication. Unfortunately, in most cases, the diet is ineffective, because in many people the cholesterol level is so high that a he althy lifestyle, i.e. diet, exercise or weight loss, is no longer sufficient. Then you need to start treatment as soon as possible, because long-lasting high cholesterol is an independent risk factor for complications such as heart attack, stroke, cardiovascular death, sudden cardiac death, ischemia, it can also cause heart rhythm disturbances and many, in fact, all possible complications. heart disease.
It is sometimes said that too high cholesterol is seen on the legs or on the skin. Thisright?
Absolutely. There are two types of such changes. Pain in the limbs can be of a very different nature, while severe leg pains appearing during exercise, walking and the so-called intermittent claudication, i.e. the need to rest while walking, because then the pain subsides, is a very characteristic symptom of symptomatic peripheral atherosclerosis, often as a result of high LDL cholesterol.
Such pain should never be taken lightly, as it may result from the gradual narrowing of the arteries that supply blood to the lower extremities. In such a situation, a Doppler ultrasound examination of the lower extremities is necessary, which will show whether it is a symptom of atherosclerosis or the pain is related to innervation or rheumatic diseases. Cholesterol deposits, the so-called yellow tufts, they can also accumulate in the skin, on the eyelids, in the interphalangeal tendons of the hands or Achilles tendons, as well as on the knees - but if we can see it, it is a sign that the level of LDL cholesterol is very high and it is very, very much long.
At this point, we should immediately think that we may be dealing with family hypercholesterolaemia, i.e. a genetically conditioned disease in which, if the mother is sick, every second child will also be sick - inheriting it is because as much as 50 percent. opportunities. A person with such changes should see a doctor as soon as possible and have cholesterol tests done. Fortunately, nowadays in the age of statins, we observe less and less such typical accumulation of cholesterol in the tendons or just under the skin, although of course there are still such patients, especially in smaller towns, where not only patients are not aware of it, but often, unfortunately, also doctors who symptoms ignore. Meanwhile, these are symptoms that are very pathognomonic for the occurrence of familial hypercholesterolaemia, in other words - their detection in a patient is often enough to make an accurate diagnosis.
Suppose a patient has done tests and the result shows that his LDL cholesterol level is much too high. What could have made him reach such a level?
There are two primary reasons. The first, primary, is genetically determined - the already mentioned family hypercholesterolaemia, when a child is born with an elevated LDL cholesterol level and has it throughout his life. In this case, early diagnosis and the fastest possible implementation of non-pharmacological measures and treatment are of great importance, because thanks to this, such a person has a chance for a normal, long life and avoiding all complications related to this disease. In the course of familial hypercholesterolaemiasymptoms such as myocardial infarction or stroke appear faster than in he althy people - even in the 2-4 decade of life - ischemic heart disease occurs much more often than in people without this disease, which may manifest itself, inter alia, with exercise intolerance and chest pain. The risk of death is also higher.
The second cause of too high LDL cholesterol is secondary - it is most often an inappropriate, too fatty diet, sometimes also comorbidities or medications. Usually, however, we consume too much fats with food - the body is unable to metabolize them, and the excess accumulates in various places, including, unfortunately, in the arteries and coronary vessels, leading to endothelial damage and the formation of atherosclerotic plaque.
So who should have blood tests for high cholesterol? Are thin people also?
Basically everyone should do such tests, and body shape or weight do not matter here. Anyone can suffer from familial hypercholesterolaemia. Our observations show that people without obesity or overweight, without diabetes or other risk factors, often regularly practicing sports, have this disease much more often. They may not know that they are genetically predisposed to have high LDL cholesterol values. As for the general population, especially people over 40 should have their LDL cholesterol level assessed at least once a year to see if an intervention is needed.
Especially that we now have the Prevention 40plus program - imperfect from the cardiologist's point of view, because only total cholesterol is assessed in the tests, but even the result of this test may indicate that in-depth diagnostics is necessary. The question of tests in patients with already diagnosed cardiovascular disease, including those after a heart attack, is different. After the initiation of treatment, we check the level of LDL cholesterol every 4-6 weeks until we achieve the therapeutic goal, and then every six months.
Can high LDL cholesterol be effectively treated?
Of course, there are quite a lot of drugs, and I hope there will be more in a moment. These are mainly statins. But unfortunately, we do not use them in appropriate doses - the highest doses of statins in Poland are used by less than five percent of patients, which is a huge mistake, because treatment of too high LDL cholesterol is not as effective as it could be. Besides, such treatment is lacking not only in Poland.
Therefore, in the Polish guidelines for the treatment of lipid disorders, we strongly emphasize the need for useoptimal, maximum tolerated doses of statins by the patient. In order to achieve the therapeutic goal, patients are also prescribed ezetimibe, a very effective drug, which by 15-20 percent. lowers the level of LDL cholesterol by inhibiting the reabsorption of cholesterol from the intestines and bile. There are also new generation drugs, including PCSK9 inhibitors, which inhibit the PCKS9 protein involved in cholesterol metabolism, and they, in turn, can reduce LDL cholesterol levels by up to 60 percent.
Bempedia acid will appear in a moment, which is a prodrug - it is inactive in the muscles and becomes active only in the liver, which is extremely important from the point of view of postatin side effects - mainly related to muscles. This drug is effective in lowering LDL-C cholesterol by up to 20% and is safe - it can be extremely useful. Triple therapy with bempedia acid in combination with a statin and esimibe can give us even a 70 percent reduction in LDL cholesterol. In turn, in the case of very high or extreme risk patients, e.g. with family hypercholesterolaemia or after a heart attack, triple statin therapy in the highest dose, esimibe and PCSK9 inhibitors can lower LDL cholesterol levels by up to 85%.
It is a truly incredible possibility of effective therapy for over 90 percent. patients, although there are of course cases of homozygous familial hypercholesterolaemia, where the initial LDL cholesterol level reaches 500, 600 or 1000 mg / dl and then we often use LDL apheresis, which is a mechanical method of removing LDL particles from the serum.
So we have a really large group of drugs, although due to the reimbursement provisions, unfortunately not all patients can use them, but we are constantly fighting for it.
What about too low LDL cholesterol? Is he also dangerous?
No. Patients treated with triple therapy can achieve very low levels of LDL cholesterol, the lowest I have observed in a patient was 8 mg / dL. There are no data linking very low LDL cholesterol values with long-term complications. All the data at our disposal clearly indicate that extremely low LDL cholesterol is safe, there is no progression of atherosclerosis and no side effects.
There have been reports at the time that too low LDL cholesterol levels may increase the risk of hemorrhagic stroke, but there is no proven causal relationship for this complication. There is an association between treatment with very high doses of statins and new cases of diabetes mellitus, but a benefit in reducing cardiovascular eventsassociated with statin treatment is five times greater than the risk of new cases of diabetes.
There is also no confirmation of the association of statins with neurocognitive disorders, which is also often discussed. In turn, for other dementia-related disorders and Alzheimer's disease, we have very good data, which confirm that low LDL cholesterol values have a very positive effect on the symptoms associated with these diseases.
Is it possible to lower cholesterol without medication?
Treatment of hypercholesterolaemia is always combined treatment, and non-pharmacological methods are part of it, they are always part of the treatment, because treatment of lipid disorders is always combined treatment. The bottom line is a lifestyle change that can ultimately lower LDL cholesterol by about 20-25 percent. Here, the most important is a low-cholesterol, low-fat diet, necessarily well-balanced, but not restrictive, because restrictive diets used for a long time, except in rare cases, are very detrimental to he alth.
The quality of fats is very important in the diet - they should be mainly polyunsaturated fats. The content of saturated fatty acids should not exceed 7% - the lower the better. Avoid fashionable diets, because they are often simply unhe althy. A proper diet can lower cholesterol by up to 12 percent. Another piece of the puzzle is regular exercise, which can lower LDL cholesterol by about 5-7 percent, it also lowers triglycerides, inflammation, and increases the level of "good" HDL cholesterol.
Weight loss is an important element of the change of style, which is extremely important in the treatment of lipid disorders. Following these therapeutic recommendations can lower LDL cholesterol levels by 20-25%, i.e. if the test result is around 140 mg / dL, and the therapeutic goal is 115 mg / dL, there is a chance that changing your lifestyle will suffice. Unfortunately, drug-free LDL lowering is only successful in one in five patients, as only one in five follows these lifestyle changes. This is especially true for people in their 30s, 40s, and 50s who feel he althy and elevated LDL doesn't mean much to them. Then it is necessary to include drugs or nutraceuticals - depending on the situation and cardiovascular risk.
Finally, I can't help but ask this question: butter or margarine?
The discussion on this topic has been going on for years. Butter is definitely better because margarine is a processed product. But when choosing butter, let's read the labels. Let's choose a product, wwhich are as little saturated fatty acids as possible and as many polyunsaturated fatty acids as possible.
Prof. dr hab. n. med. Maciej Banach, specialist in the field of cardiology and lipidology
Head of the Department of Preventive Cardiology and Lipidology, Medical University of Lodz, founder and chairman of the Polish Lipidology Society, secretary general of the European Society for Atherosclerosis Research (EAS), founder and president of the International Lipid Expert Panel, founder of the Lipid and Blood Pressure Meta-analysis Collaboration (LBPMC) Group - a group of over 150 global experts whose goal is to study the most important issues in the field of lipid disorders, hypertension, nutrition and cardiovascular risk.