Jan 20, 2016


Interviewer: Did you know you could decrease your risk of heart attack and stroke by focusing on your cholesterol levels? We're going to find out more about that from Cardiologist Dr. John Ryan, next on The Scope.

Announcer: News and research from University of Utah Physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: While trying to reduce your risk of heart disease and making sure your heart stays healthy, there are a lot of components that go into that, including diet, reducing blood sugar, watching your weight, not smoking, exercising, managing your blood pressure. And one of them is controlling your choleterol. Dr. Ryan, how important is controlling cholesterol levels in relation to heart disease, stroke?

Dr. Ryan: Cholesterol levels have long been identified as one of the major predictors of heart disease and the development of clinical events, heart attacks, strokes, heart failure, etc.

Interviewer: So, as a doctor, you see high levels of cholesterol, you've got a pretty good idea that that might be what's in the future?

Dr. Ryan: They're at higher risk of having these events and that's been identified from the early days of the Framingham heart study and has been a consistent target of cardiovascular investigators for many, many decades. There's the so-called . . . the American Heart Association has changed the language in terms of people focusing on the good cholesterol and the bad cholesterol. Bad cholesterol being typically being the LDL or the low-density lipoprotein, and good cholesterol being the HDL, or high-density lipoprotein.

The issue being if you have a low LDL, low bad cholesterol, you have a decreased risk of having a heart attack. And if you're going to have a high HDL, you're going to have an increased risk of having a heart attack. There are many folks, and in particular Eugene Braunwald, who's one of the most senior cardiologists in the country, has said you can never be too rich, too tan, nor have too low an LDL cholesterol. It's that much of a risk factor for heart disease.

Interviewer: How much does monitoring cholesterol contribute to decreasing your risk of heart attack in terms of the seven things that I talked about?

Dr. Ryan: I think you can be useful for motivation. I think people, numbers are useful. We follow numbers on the stock market every day. We listen to the marketplace to tell you what has gone up and what has gone down, and it seems to motivate folks. And I think that's where LDL cholesterol is useful as well. You can watch the numbers. It does respond well to changes in your diet, changes in your exercise habits. It does respond well to medications as well and is reflective that you have now decreased your risk of having an event. You haven't brought it to zero, but you've decreased your risk.

Similarly, the opposite is also true that often times people say, "Well, I've been taking this medicine for five years. How do I know it's still working"? And sometimes folks like to come off their medicines for three, six months at a time just to see what happens. And it that regard, it can be useful as well that you come off the medicine. Your cholesterol LDL level goes from a target level of 68 to 168, and you can say that by stopping that medicine, you have increased your risk of having a cardiac event so we should get your statins back on board.

Interviewer: If you have patient in your office and they need to change their lifestyle a little bit to get their cholesterol more under control, how do you encourage them to take it seriously because, I mean, it takes effort, right?

Dr. Ryan: Yes. So what I do, at least in our clinic, when we discuss with folks coming to see us for an evaluation of their heart disease and the setting of cholesterol is it's all about risk and it's all about risk factor modification.

One of the useful things that have been released by the American Heart Association and the American College of Cardiology is a risk calculator. It's the ASCVD calculator, it's available online. It's freely available, but imputing parameters such as blood pressure, smoking status, blood pressure medications, you can estimate their risk of having a heart attack over the next 10 years. Then by imputing things such as if you start this medication, such as a statin, you can then see what the risk of having a heart attack over the next 10 years is.

Interviewer: Oh, cool. So then you can change other factors and see how that affects your risk as well. What about diet? How important is diet in keeping your cholesterol low?

Dr. Ryan: The science around diets is very difficult and the conclusive science around diets can be challenging. So the diet that has shown most conclusively to be associated with lowering your cholesterol and having a decrease heart attack risk is the Mediterranean Diet.

The interesting thing in particular about the Mediterranean Diet is when you actually look at folks who consume the Mediterranean Diet and look at folks of a US-based diet, even if their LDL cholesterol, their bad cholesterol, ends up being the same, the folks who have been consuming the Mediterranean Diet have a decreased risk of having a heart attack compared to the US diet.

So I think the goal with all of this is, as I said, to decrease your risk of a heart attack, decrease your risk of a stroke, and lowing your cholesterol is a large part of doing that. And then trying to get 30 to 60 minutes of exertion five to seven times a week, as well as not smoking and watching your weight.

Interviewer: And sometimes, medication is required.

Dr. Ryan: Yeah, sometimes, if you have had a history of a heart attack, if you have had a history of stroke, your risk of having another event is so much bigger than you and me, assuming that neither of us has had a heart attack or a stroke. And in that circumstance, diet and exercise alone may not be adequate in order to make you as low risk as possible. So that's where the discussions evolve in terms of when is the time to add on medications to lower my cholesterol.

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