Asking the world’s best cardiologist: How low should you go on LDL cholesterol?
The “life & death” importance of lowering LDL
Heart disease reigned supreme as the leading cause of death in the United States and is responsible for almost 35% of all deaths in the US.
One of the reasons cardiovascular disease is so deadly is that the medical system’s current, traditional methods of detection miss 70% of all patients who will suffer a heart attack, mistakenly labelling them “low risk".
Heart disease – and more specifically, coronary atherosclerosis, which is responsible for the majority of deaths from cardiovascular disease – is, to quote Peter Attia: “easily the most preventable of all the “four horsemen of chronic disease” (i.e., heart disease, cancer, neurodegenerative disease, and metabolic disease).” Therapies for lowering circulating LDL levels – such as statins – have the power to virtually stop atherosclerosis in its tracks. So why does this disease remain a top killer? A study published last month provides some insights, along with further evidence of the importance of lowering LDL as a means of preventing atherosclerosis-related mortality.
Study authors Faridi et al. analyzed data from the Miami Heart Study, which involved participants who were 40-65 years of age and free of any clinically evident cardiovascular disease (CVD) at enrollment.
Why so deadly?
So why is atherosclerotic cardiovascular disease so deadly despite the existence of effective treatments? The results of the present study suggest a simple (albeit alarming) answer: millions of individuals with this disease are likely unaware of it. Atherosclerosis develops over decades of exposure to high levels of circulating apoB-containing lipoproteins, yet for those who are relatively young or otherwise healthy, both patients and physicians often ignore the possibility of coronary artery disease, failing to test for it.
These results align with a large, consistent body of evidence indicating that apoB-containing lipoproteins drive the development of atherosclerosis – and that reducing serum levels of apoB-containing lipoproteins, for instance with statins or PCSK9 inhibitors, can slow or halt the progression of this disease and help to prevent subsequent major adverse cardiovascular events such as heart attacks or strokes.
The data show that apparent health is no guarantee of the absence of CVD, and as we know, being proactive about lipid and imaging tests – and following up with appropriate treatments – can literally be the difference between life and death. On a population scale, these actions have the power to put an end to mortality from coronary atherosclerosis.
Asking the world's best cardiologist: How low should you go on LDL?
Ok, cardiology was not a category in the Olympics so we do not know who is the best heart doctor in the world. But given how Doctor Eric Topol is framing his question to Doctor Natarajan (on the latest episode of the Ground Truths podcast, we are not that far off):
“You're running preventive cardiology at man's greatest hospital. Could you tell us what is your recipe for how aggressive do you go with LDL?
Here are some quotes / answers from Doctor Natarajan (who apart from running preventive cardiology at Mass General Hospital and also is on faculty of Harvard Medical School).
- “For those individuals “at risk” it makes lots of sense to get it as low as possible…”
- “I mean increasingly with these trials we'll see it going down really low and then we'll better appreciate and understand, so we'll see 40* is probably the right range”.
- “You could say, okay, maybe everybody should be on pharmacotherapies, and I think if you did that, you probably would reduce a lot of events.”
*40 is less than half of current guidelines.
All-in-all, do not just sit around and ignore your health. Be pro-active and find risks early.
Sources: Peter Attia, Harvard Medical School, Mass General, American Heart Society, Eric Topol