Keeping Cholesterol in Check for Heart Health

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Cholesterol is an essential element of human life, but too much of the wrong kind can raise your risk for cardiovascular disease and stroke. Understanding how cholesterol works – and what you can do to keep it in check – is the first step toward protecting your heart health.

Cholesterol is a natural, fatty substance found in every cell of the human body. It’s important for building cell walls, producing hormones and even aids in digestion. Cholesterol cannot travel through the bloodstream on its own, so the body transports it inside protein carriers called lipoproteins. 

Two types of Lipoproteins:

1. LDL (low-density lipoprotein) – Often called “bad cholesterol”, LDL cholesterol can build up as plaque in the arteries in increased amounts, raising the risk for heart attack and stroke.
2. HDL (high-density lipoprotein) – Known as “good cholesterol”, HDL cholesterol helps transfer excess cholesterol to the liver where it can be broken down.

When it comes to LDL cholesterol, typically the lower this number, the better. Generally, an LDL of <100mg/dL is recommended for people without heart disease. For people who have had a heart event, LDL cholesterol levels between 30-70 mg/dL is ideal. In terms of HDL cholesterol, typically the higher this number, the better.  For women, the goal is >50mg/dL and for men, the goal is >40mg/dL. 

Lifestyle vs Genetics

When it comes to cholesterol levels, both lifestyle and genetics play a role. Regular exercise can boost your “good” HDL cholesterol and lower LDL and triglycerides (another type of fat related to cholesterol). Filling your plate with fruits, vegetables, and healthy fats (like those from fish, nuts, and vegetable oils) helps too; on the other hand, an eating pattern heavy in saturated fats and processed foods tend to push cholesterol in the wrong direction. That said, only about 20% of cholesterol is affected by the food we eat. The other 80% is produced by the liver and is largely determined by genetic factors. 

When to Seek Treatment

While regular exercise and heart healthy eating are recommended for everyone to reduce the risk of cardiovascular disease and stroke, that may not be enough for some. The following four groups should consult their primary care provider (PCP) to see if they’d benefit from treatment to reduce their risk of cardiovascular disease and stroke:

• Individuals with prior cardiovascular disease (including a previous heart attack, stroke, bypass surgery or stents, or peripheral artery disease)
• Those with genetically high cholesterol (LDL of 190 or greater)
• People with diabetes (a risk factor for cardiovascular disease)
• Individuals who don’t fall into the previous three groups but are still at elevated cardiovascular risk (for example, due to smoking, family history, high blood pressure or an elevated coronary artery calcium score) 

The Nolan Family Center for Cardiovascular Health offers additional resources for calculating cardiovascular risk. Your doctor can best determine if cholesterol medications are right for you.

In these cases, statins are often the first medication PCPs recommend; they work by reducing the amount of cholesterol produced in the liver. Studies have shown statins can lower LDL by 30-60% with significant reductions in heart attack and stroke. These cholesterol medicines are relatively inexpensive and generally well tolerated with 1 in 100 patients experiencing true side effects, the most common of which are muscle pain or cramping. 

Non-statin treatment options:

• Ezetimibe – This daily pill works in the intestine to block cholesterol absorption. Studies show it reduces the risk for heart attack and stroke without side effects – and typically lowers LDL by about 20%. It’s also a relatively inexpensive option.
• PCSK9 Inhibitors – These treatments work by blocking a protein that causes the liver to produce more LDL receptors, clearing more cholesterol from the blood. Although they are highly effective, they can be expensive and require self-injection every two weeks. Inclisiran is an exception; this unique PCSK9 inhibitor is injected every 6 months.
• Bempedoic Acid – This medication acts and lowers cholesterol similar to statins but has fewer muscle-related side effects. A recent trial shows success in reducing cardiovascular-related events.

Aside from these medications, there is also evidence to indicate that supplements can offer mild decreases in LDL levels. While this option may sound appealing, there is no research to show these supplements reduce the risk of cardiovascular events – the ultimate treatment goal. It’s also important to note that dietary supplements are not regulated by the FDA, and that raises concerns about their quality and safety. For those who need treatment, proven medications remain the cornerstone of care.

Next Steps

At the end of the day, understanding cholesterol and taking steps to keep it in check are great ways to manage the risk of heart disease and stroke. Many tools are available to support this goal. Healthy eating and regular exercise benefit everyone, and today’s medications are both effective and safe for those who need them. Working closely with a doctor is key to establishing an individualized care plan. Taking time to talk through options can make a lasting difference for heart health.