1) Question - Why hasn’t my doctor prescribed medications for me to prevent a heart attack?
Answer – It takes approximately 10 years for new discoveries in medicine to reach the patient to improve health care. Most of the new discoveries in preventing heart attacks have occurred in the last five years so this knowledge has not yet reached your physician. We are trying to shorten this period by letting you know that heart attacks can be prevented.
2) Question – I don’t like to take medications. Is there another way to prevent heart disease?
Answer – Yes, there is but most people do not want to follow it. If you become a strict vegetarian (no animal products such as eggs, cheese, and milk), your LDL cholesterol might drop below 60 mg/dl. However, this is not guaranteed because you may have been born with too high an LDL level to drop it low enough. You would have to try the diet and see what happens.
3) Question – I have already had a heart attack. Is there any benefit to me to have my LDL below 60mg/dl?
Answer – Absolutely. People who have had a heart attack have multiple plaques in their coronary arteries. These plaques can rupture and cause another heart attack in a different location. You need to stabilize all of your plaques and prevent a future heart attack which may be lethal. In fact, because you are at very high risk for another cardiac event, we would prefer to have your LDL in the 40 mg/dl range.
4) Question – My doctor already has me on a statin but my LDL is 90 mg/dl. What should I do?
Answer – This is a common situation. You are not adequately protected against having a heart attack. There are several things you need to do. First, you need to look at what statin you are taking. You may need to be on a more potent statin. If you are not taking either atorvastatin or rosuvastatin, ask your doctor to change your medication. Second, you should ask your doctor to prescribe ezetimibe. It blocks cholesterol absorption from your intestine and will lower your LDL about 20%. Third, you need to remove saturated fats from your diet (see the diet picture at this web site). If you adhere to these recommendations, you will see a dramatic reduction in your LDL level.
5) Question – The medications that you suggest are expensive, even with my copay. What should I do?
Answer – We agree that the medications to prevent a heart attack are expensive. They will be a significant burden on most people’s income. The good news is that eventually they will all be generic and therefore have a lower copay. However, you need to ask yourself two questions: first, what will my hospital bill be if I have to go to the emergency room with chest pain and maybe a heart attack. Second, what is my life worth (50% of people die with their first heart attack)? The answers are (of course) that it is much better to take medication than to have a heart attack. Ten years ago we did not have this choice.
6) Question – What about the side effects of the statins? The information on the internet says they are dangerous.
Answer – Every scientific study that has been published has concluded that the risk of taking these medications is much less than the benefit that the medications give you. This is even true for people who have not had any heart attack events (this is called primary prevention). Furthermore, the incidence of side effects is very low and reversible when the medications are stopped. The information on the internet is not based on any scientific studies. It is based on someone’s opinion.
7) Question – I am convinced that I cannot take a statin because of side effects – what should I do?
Answer - Recent studies have clearly demonstrated that almost all people who are certain that they cannot take statins for various reasons in fact can take statins when given either a statin or a dummy pill (a placebo). However, for individuals who will not be dissuaded, it has been shown that significant benefit can be derived from trying half (5 mg/d) of the lowest dose of either atorvastatin or rosuvastatin. If fact, 5 mg of Rosuvastatin each week is beneficial in lowering LDL. We have successfully used this approach in several of our patients.
8) Question – My LDL is very high even on a high dose of statin. Are there any new medications on the horizon that will help me?
Answer – Yes there are. Several pharmaceutical firms are asking the FDA to be able to sell a new class of medications called PCSK9 inhibitors. These drugs are taken by one injection in the skin every two to four weeks. They work very well in conjunction with statins and ezetimibe. They were developed for people like yourself with very high LDL levels. We expect they will be available within the next 12 months. We will add them to this website when they become available.
9) Question – What can I do in addition to medications to reduce my risk for a heart attack?
Answer – The causes of a heart attack are multiple although your LDL level is the principle determinant. You should work to improve the risk factors that are amenable to change. Obviously, you cannot change your gender, your family history, or your age. What you can improve is your blood pressure, glucose control, LDL levels, diet, body weight, smoking, and exercise patterns. A healthy lifestyle is important.
10 ) Question – My doctor says that I am fine with my LDL level at 80 mg/dl even though I am a 55 y/o male, my father and his brother both died of a heart attack, and I used to smoke cigarettes. What should I do?
Answer – You should ask your doctor to order you a cardiac calcium CT score. This is a noninvasive test (no injections) that has been shown to be an excellent way to assess what your risk is. Do not settle for a cardiac stress test which is very insensitive for risk assessment. Based on this score, treatment recommendations should be clear. You can learn more about this test by going to the calcium score section of the Home page on this web site.
11) Question - Is an LDL cholesterol level around 40 mg/dl safe?
Answer - All the available scientific information indicates that very low levels of LDL cholesterol are safe. Here are the reasons: 1) in all the big statin clinical trials, there have been some individuals who have achieved a very low LDL-cholesterol level. No untoward side effects have been observed in these individuals - in fact, they seem to do better than individuals with higher levels of LDL cholesterol. 2) There are individuals who have genetic reasons to have very low LDL cholesterol levels (as low as 14 mg/dl! These individuals are all healthy and leading normal lives. 3) All cells in the body can make their own cholesterol so they do not need circulating LDL cholesterol for their own use. And 4) most people were born with a LDL cholesterol level in the 40 mg/dl range and did fine until they began to eat a Westernized diet.