... about cholesterol

By Julia Cyboran

William also intends to ask his doctor if prescription drugs can help him — he learned from a recent news report that treating high cholesterol with certain meds can cut the risk of heart attack and stroke.

Patients nowadays are more cholesterol savvy and may very well flock to your office with questions and requests about the latest treatments to hit the market. Heart attacks are the number one killer in this country, so it's easy to see why more and more patients are taking a keen interest in how to better control their cholesterol levels. Here are some tips on how to talk to your patients about their high cholesterol levels and what steps they can take to keep it in check.

CHOLESTEROL: THE GOOD, THE BAD AND THE TOTAL
Check it out "Everyone should be checked for high cholesterol by the age of 40," says Dr Ruth McPherson, a spokesperson for the Heart and Stroke Foundation and director of the Lipid Clinic at the University of Ottawa Heart Institute. She adds that patients with risk factors like smoking, abdominal obesity, diabetes, a family history of high cholesterol, or those who show early signs of heart disease need to get checked earlier.

Where to draw the line Interpreting cholesterol levels from blood work isn't easy for many patients. The first thing they need to learn is that cut-offs for acceptable levels of low density lipoprotein (LDL), high density lipoprotein (HDL) and total cholesterol aren't set in stone. "It of course depends on the breakdown of the amount of LDL and HDL, and if [they] have a history of heart disease," explains Dr McPherson. There are two numbers that Dr McPherson — who co-authored the most recent Canadian cholesterol guidelines — says patients should remember: their LDL (the bad cholesterol) and total cholesterol levels. "LDL cholesterol should be less than 3.5mmol/L if the patient is healthy," says Dr McPherson, "and if the patient is at high risk it should be less than 2.5mmol/L or 2.0mmol/L." In terms of total cholesterol, healthy folks should aim for 5.0mmol/L or less. For those in the high-risk bracket, 4.0mmol/L or less is ideal.

Dietary damage control Once you've established which patients have high cholesterol, there are a few important changes they'll have to make to get their levels back to normal. "If cholesterol is moderately elevated and there is no history of heart disease, we start with diet," says Dr McPherson. Tell patients to cut down on saturated fats, trans fatty acids and cholesterol, and increase their consumption of fruit, vegetables and polyunsaturated fats. Dr McPherson also adds that exercise can help to lower blood triglycerides. One interesting point you can pass along to your patients is that if they make these changes, they won't have to wait long to see results. "If [they] simply cut out bad fats and cholesterol from [their] diets, it takes two weeks for it to affect the cholesterol levels."

When meds come into play If lifestyle changes don't work to lower blood cholesterol, medication is the next step. "The most effective drugs are statins," says Dr McPherson, "they will lower cholesterol up to 60%." She also mentions that drugs like ezetimibe can be really effective as a second agent — it lowers cholesterol by about 20%. Fibrates are another class of drugs often recommended for patients with high triglycerides. Besides drugs, niacin — a B vitamin — can also help control cholesterol. Although niacin is available over the counter, Dr McPherson suggests that you stress to patients that they need to take this supplement under your supervision as it can cause some side effects, such as flushing, itching and even liver function abnormalities if taken at high doses.

A healthy dose A study published online on March 8 in the New England Journal of Medicine concludes that high doses of statins can drop cholesterol to very low levels and help patients with heart disease reduce their risk of heart attack or stroke. The study demonstrates that getting LDL under 2.0mmol/L will help those who already have heart disease, comments Dr McPherson. "A high dose is particularly useful with [these patients]," she says but cautions that each drug is different and that it might be better to start with lower doses especially with the newer statins as there's less clinical data available on them. Also, their safety profiles aren't as well established as the older statins.