About one in three American adults have elevated levels of LDL (bad) cholesterol, a major risk factor for developing atherosclerosis (plaque buildup in the arteries). The American Heart Association (AHA) and American College of Cardiology (ACC) have issued new cholesterol management guidelines for healthcare providers, aimed at helping patients lower their risk for heart attack, stroke and death from cardiovascular (CV) causes.
The new guidelines have several important changes from earlier ones issued in 2013, including new recommendations about evaluating patients’ CV risk and new treatment options for those at increased risk. Here’s a closer look at what’s new in the guidelines, four key takeaways from the BaleDoneen Method, and how to work with your healthcare provider to optimize your arterial wellness and cholesterol levels.
A heart-healthy lifestyle is the first — and best — line of defense against heart disease. The new guidelines place a strong emphasis on “lifestyle therapies” to protect and improve heart health, such as losing weight, smoking cessation, and eating a Mediterranean diet that that emphasizes fruits, vegetables, fish and other lean protein, healthy oils (such as olive oil) and nuts. The guidelines also advise aerobic exercise, such as brisk walking, jogging, biking, dancing or jogging, at least three to four times a week, for an average of 40 minutes per session. Lifestyle improvement is particularly advised if you have metabolic syndrome, a gang of five cardiovascular villains that triples risk for heart attack and stroke and quintuples it for type 2 diabetes.
BaleDoneen takeaway: Lifestyle changes, such as moving more, avoiding all forms of nicotine exposure and kicking the sugar habits, offer remarkably powerful protection against a heart attack or stroke, cutting risk by up to 90%. However, studies of the best dietary approach to reduce heart attack and stroke risk reveal striking individual differences in response. That is why we recommend a diet based on your DNA.
Talk to your healthcare provider about your risk for heart attacks and strokes. Americans have long been told to “know your numbers.” However, LDL cholesterol numbers are not a reliable predictor of CV risk. For example, a 2009 study of 136,095 people hospitalized for a heart attack reported that nearly 75% had “normal” levels of LDL and nearly half had “optimal” levels, based on the guidelines in effect at that time. For patients who have not yet had a heart attack or stroke, the new guidelines urge healthcare providers to evaluate patients’ CV risk in two ways. First, a population-based risk calculator introduced in 2013 is used to predict the person’s 10-year CV risk. The prediction is personalized by weighing a wide range of factors, including the patient’s age, ethnicity, family history, other medical conditions and results of certain blood tests, along with traditional risk factors as smoking, diabetes and high blood pressure.
BaleDoneen takeaway: We strongly support a personalized, precision-medicine approach to heart attack and stroke prevention, rather than treating patients based on the average results of large clinical trials. We are also happy that the guidelines discuss testing to check for inflammation, which has now been proven to cause atherosclerosis — and, in people who have it, is also the trigger of heart attacks and most strokes. The new guidelines also discuss lipoprotein (a), a dangerous type of cholesterol that most American doctors do not check, despite the availability of a $20 test to measure it.
Ask to have your arteries checked for plaque. The biggest improvement in the guidelines is that for first time, medical providers are encouraged to use an imaging test called coronary artery calcium score (CACs) to check certain seemingly healthy patients for arterial disease. The guidelines also advise that anyone with a score greater than zero on this test, which looks for calcified plaque, be treated with statins.
All previous guidelines from the AHA and ACA advised basing treatment decisions solely on the patient’s risk factors, such as cholesterol levels.
BaleDoneen takeaway: Unlike standard care, which considers patients “innocent” of heart disease unless they have certain risk factors, the BaleDoneen Method considers all patients to be “guilty” of harboring silent, potentially lethal plaque unless they are proven innocent through imaging and laboratory testing that directly checks for arterial disease.
As discussed above, many people who have heart attacks and strokes lack traditional risk factors, while other people with many risk factors never suffer these events. Therefore, rather than trying to guess who is at risk based on cholesterol or other numbers, we check every patient for plaque, regardless of risk factors. CACs is an excellent imaging test, but can only detect calcified plaque, a relatively late sign of arterial disease. A 15-minute ultrasound exam of the neck arteries, called intima-media carotid thickness, can also detect soft plaque (the most dangerous kind).
If you have arterial plaque or are at elevated risk for developing it, talk to your medical provider about the latest treatment options. Until recently, the main treatments for cholesterol management were lifestyle modification and statin drugs. If these treatments are not effective enough, the new guidelines also recommend use of non-statin drugs, such as ezetimibe and PCSK9 inhibitors, for certain patients. Currently, there are two FDA-approved PCSK9 inhibitors: alirocumab (Praluent) and evolocumab (Repatha). Recent studies suggest that these drugs can help prevent heart attacks and strokes, but they are much more expensive than other cholesterol drugs.
BaleDoneen takeaway: Statin drugs don’t just lower cholesterol, they also reduce inflammation and make plaque less likely to rupture, helping to reduce risk for heart attacks and strokes. Because PCSK9 inhibitors are new, it’s not yet known if they have additive value in reducing inflammation. We recommend that statin therapy be personalized based on the patient’s genes and gender. It’s also important to realize that statin therapy is not effective for people with elevated lipoprotein (a), an inherited condition found in about 20% of the US population. If you have elevated levels of this cholesterol, taking niacin (vitamin B3) under medical supervision can reduce levels by up to 40%, according to the European Atherosclerosis Society.
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