Category: Hyperlipidemia

Categories
Heart Health Hyperlipidemia Treatment

Should We Be Testing for Lp(a)?

No doubt those with elevated Lp(a) have a higher risk of ASCVD, but the question is whether testing for Lp(a) is beneficial if we don’t have effective therapies for lowering it.

Lipoprotein (a)

It isn’t the best nomenclature, but this word refers to a low-density lipoprotein containing a particular molecule called apolipoprotein(a) or Apo(a).

The blood levels of Lp(a) are affected by a few factors, one of which, of course, is the LPA gene that encodes this molecule. Dietary habits, age, or sex don’t seem to affect your Lp(a) values.

It’s important to check for Lp(a) in the same lab for monitoring levels, but it may not be the best way to work with this lab value. Most experts will check this one or two times in the patient’s lifetime because it’s meant to be an indicator of overall risk.

Lp(a) is made up of a liporptein plus ApoB and Apo(a). The Apo(a) portion can independently elevate the risk for clotting.

Lp(a) & Disease Association

We know from observational studies that those who walk around with higher Lp(a) levels tend to have a higher risk of ASCVD, coronary heart disease (CHD), cerebrovascular disease (CVD), and aortic stenosis.

This molecule is also an acute phase reactant, so those with inflammation will have higher values. Meaning also it shouldn’t be checked during times of inflammation.

From a UK study of half a million individuals we know that for levels above 20 nmol/L there was an increased association with ASCVD. Which translates to a 10% higher risk for each 50 nmol/L increment above this value.

Lowering Lp(a)

Unlike someone’s LDL values, we don’t have good tools to lower a patient’s Lp(a). At least, that’s the current widespread consensus. Some experts believe there are treatments (medications) in the pipeline that will lower the serum level of Lp(a) but as much as 80%.

The next question is whether lowering Lp(a) levels would change someone’s health outcome.

With HDL and homocysteine levels, we have seen that changing the value of these in the blood through directly targeted medications doesn’t have an actual cardiovascular disease outcome.

So, we’ll see if medications that lower Lp(a) will change a person’s ASCVD. Some of the upcoming clinical research should reveal that.

How To Treat Elevated Lp(a)

Some countries, such as the UK, regularly test their patients for Lp(a). But all countries are still waiting for final results to figure out which Lp(a) lowering treatments will actually lower the risk of atherosclerotic heart disease.

It’s important to recognize that statin therapy can sometimes elevate Lp(a). Again, this is the tough part of understanding the complicated interplay between the different key players in heard disease.

Fortunately, despite the rise in Lp(a) caused by statins, those at risk will still benefit from statin’s independent anti-inflammatory and LDL lower effects.

1. PCSK9 Inhibitor

Though PCSK9 inhibitors seem to lower Lp(a) values, it’s unclear whether they can lower the risk of heart attacks in those with high Lp(a) values.

2. Lipoprotein Apheresis

Similar to dialysis, though not as severe, this can be used weekly to lower Lp(a) values by 70% or more.

3. Antisense Therapies

Some antisense oligonucleotide treatments are being researched to lower patients’ Lp(a) levels.

4. Inclisiran

Leqvio is a medication for those with elevated ASCVD disease risk who may not be candidates for standard treatment alone.

This molecule works in the synthesis pathway of the PCSK9 protein.

Serum Lp(a) Values

Serum values above 165 nmol/L seem to be associated with the highest risk such as coronary heart disease death, heart attack, or needing immediate vascular intervention.

Some believe values above 125 nmol/L equate to elevated risk, and other experts set that bar at 50 nmol/L. The patient’s clinical history obviously matters a lot.

Categories
Diet Heart Health Hyperlipidemia Prevention Statins Treatment

How the Body Regulates Cholesterol

In this article, I wanted to provide a basic overview of cholesterol regulation in the body. I share such articles with my heart health coaching clients whenever necessary. How the body regulates cholesterol is relevant to choose the right method of controlling cholesterol levels.

Cholesterol Regulation

Cholesterol is quite essential. The following key players regulate cholesterol in the body:

  • cells lining the intestine
  • liver
  • pancreas
  • intestinal bacteria

The food we eat has some form of cholesterol which becomes absorbable after manipulation by intestinal bacteria and pancreatic enzymes.

Cholesterol can enter the bloodstream also through the bile system. Whether you still have a gallbladder or not, your liver will produce cholesterol pumped into the intestines.

Cholesterol Absorption Varies

Some individuals are hypoabsorbers of cholesterol. No matter how much high cholesterol foods they consume, their intestinal cells don’t take up much of it.

Others are hyperabsorbers of cholesterol; even the lightest meals can have every bit of its cholesterol extracted and pumped into the bloodstream.

Cholesterol Regulation and Treatment Options

For my hypoabsorber clients, I am less concerned about their dietary cholesterol intake. Their cholesterol production in the liver would be a more important factor.

The hyperabsorbers will benefit a lot from a particular dietary change. Sometimes it helps to cut back on saturated fats, but eating times and gut bacteria are also important criteria.

Dietary change? Statin therapy? Ezetimibe? Evolocumab?

To answer that, I need more information about the person. A generic cholesterol test won’t always tell us the whole story.

The Liver’s Cholesterol Production

How cholesterol is regulated in the body has a lot to do with the liver. This fleshy organ on the right upper quadrant of the abdomen produces LDL, HDL, and VLDL particles.

Statin drugs decrease the production of cholesterol molecules in the liver.

The liver also has LDL receptors and absorbs cholesterol.

From fatty liver to elevation of liver enzymes to problems with the gallbladder, it’s important to consider the health of this organ when assessing my clients.

The Role of Gut Flora and How Cholesterol is Regulated

Some bacteria in the gut convert free cholesterol molecules into a stanol chemical that intestinal cells cannot absorb.

We could call these beneficial bacteria. They can help slow down the absorption of cholesterol for certain individuals.

Ezetimibe is a medication that works similarly, blocking the absorption of free cholesterol molecules.

Categories
Heart Health Hyperlipidemia Statins

Do Statins Prevent Heart Attacks?

For the right patient, a statin is a lifesaver. But do statins prevent heart attacks? They are used to lower cholesterol levels, but some will still suffer a heart attack even when taking a statin.

It’s essential to understand this concept. You can still suffer a stroke or a heart attack while taking a statin medication.

Primary & Secondary Prevention

Statins are a group of medications such as simvastatin and atorvastatin. There are others, and each has its place in managing serum lipids.

A statin is prescribed to some patients to lower their cholesterol and prevent a heart attack, stroke, or other atherosclerosis-related medical conditions.

This primary prevention strategy is used for those who haven’t yet had a heart attack or stroke. But many will have had such cardiovascular events and be put on a statin – we refer to this as secondary prevention.

Secondary prevention means trying to prevent a second or third heart attack or stroke.

Statins and Heart Attacks

Western medicine’s big gun remains the statin drug. Even with this, nearly 25% of those on a statin still can suffer a heart attack.

I fished this number from a few studies and my personal experience with my patients. Now that even more patients are on statins, this number likely is higher.

Heart disease is a complicated process. Simply lowering your cholesterol isn’t enough to entirely prevent a heart attack. It’s a big step in the right direction – for some.

Preventing a Heart Attack

A statin won’t prevent a heart attack. It will lower a person’s cholesterol. This lower serum lipid profile may slow the progression of atherosclerosis.

A heart attack can happen in those with normal cholesterol levels. This is why it’s essential to address heart health not just from the serum lipid perspective but from a broader angle.

Whether you’ve already had a heart attack or are trying to prevent one in the first place, it’s crucial to figure out what your risk factors are.

Some of us can easily change our diets, and others will have a hard time with diet but can readily improve their exercise capacity. You’ll significantly improve heart health regardless of which strings you pull on.