Diagnosis Spotlight: High Cholesterol

A post to answer all your questions about high cholesterol.

High Cholesterol (or Hyperlipidemia) is another one of the most common diagnoses I see on a daily basis.  We hear about the link between cholesterol and serious conditions such as heart attack and stroke but don’t always know what to do with that information.  What is actually happening with cholesterol in our bodies?  In this post I want to take some time to clear up any questions you may have about high cholesterol and impart some ways you can combat it.

What is High Cholesterol?

First, we need to know what cholesterol is and how it works. Cholesterol is a waxy substance found in the blood circulating through the body.  It is necessary to help build cells but when high can cause problems.  Excess cholesterol can deposit into arteries causing plaque that can narrow arteries. This can make it hard for blood to move through the arteries and get to the tissues to deliver oxygen.  When the arteries are narrow enough and a piece of plaque upstream breaks free, it can completely block the artery causing blood to stop flowing and essentially causing death of the tissue.  When this happens in the heart it is called a heart attack. In the brain it is called a stroke.

There are two types of cholesterol in your body, LDL and HDL.  These are also know as “bad” and “good” cholesterol.  You can remember which one is which by thinking L (LDL) stands for lethal and H (HDL) stands for healthy. LDL actually stands for low-density lipoprotein which is a protein that carries cholesterol to your arteries to deposit.  HDL actually stands for high-density lipoprotein and carries cholesterol from your arteries to the liver to be removed.  You can see why one is good and one is bad.  The bad (LDL) will make your arteries clogged by depositing the cholesterol and the good (HDL) will keep your arteries clear by removing the cholesterol.  Lastly, triglycerides are a fat transported in the body.  It is used but the brain and other tissues for energy.  A normal amount is good for health but excess may raise your risk of heart disease and pancreatitis.

Causes:

There are several factors that can cause high cholesterol.  Some of these are out of your control such as the genes inherited from your parents, gender, age and race.  Some people are more inclined to have high cholesterol based on family history.  Other causes can be controlled. Poor diet and inadequate exercise can increase your cholesterol as well as being overweight or obese.  These can alter the balance between good and bad cholesterol and tip the scales to increase LDL and decrease HDL levels.

Risk Factors:

There are several risk factors that can increase your cholesterol.  They include:

  • Family history:  If your parents or siblings have a history of high cholesterol or if they have had a heart attack or stroke, your risk is increased.
  • Physical Inactivity: Exercise can help increase the “good” HDL cholesterol in your body.  Not getting enough exercise can increase your weight which increases your risk of high cholesterol.
  • Unhealthy Diet. Eating excessive fat in your diet can increase your cholesterol. Fats from animals are the main offender and should be avoided including red meats and dairy. Fats from plants are not as worrisome. Prepackaged or “boxed” foods can also increase your cholesterol because they often contain “trans” fats.
  • Obesity: A BMI (body mass index or weight for your height) over 30 classifies a person as obese and leads to increased LDL, low HDL and high triglycerides.
  • Age: Cholesterol tends to increase as you get older.
  • Gender: men tend to have lower HDL and higher LDL levels.
  • Race: Blacks tend to have higher cholesterol than Whites and Mexican men tend to be higher than both blacks and whites.
  • Smoking: Cigarettes can cause damage to your vessels.  These damaged areas are “patched” up with cholesterol and lead to plaque accumulation in the arteries. Smoking also lowers the HDL cholesterol.
  • Diabetes: Diabetes causes increased circulating sugar in the blood.  This can cause damage to the lining of the arteries and in turn cause plaque formation. Diabetes can also alter LDL and HDL level negatively.



Symptoms:

There are no signs or symptoms associated with elevated cholesterol.  The only way to find out if you have high cholesterol or no is with a blood test.  The USPSTF (United State Preventive Services Task Force) recommends routine screening for all men over 35 and women over 45 every 5 years or more often if elevated.  Men age 20-35 and women age 20-45 should be screened if at increased risk which includes those with diabetes, heart disease, family history of premature cardiovascular disease, smokers, high blood pressure and obesity.

Diagnosis:

Diagnosis of high cholesterol is based on a blood test called a lipid panel that checks 4 main components including total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides.  The lab test should be done with 12 hours of fasting to assure an accurate result.  Traditionally the numbers associated with these values would determine if one has high cholesterol.  The general levels thought to be abnormal are as follows (reported in mg/dL in the US):

  • Total Cholesterol: > 200 is borderline high and > 240 is high.
  • LDL Cholesterol: >100 is high if history of heart disease, >130 is borderline high if no heart disease, >160 is high if no heart disease and >190 is very high!
  • HDL Cholesterol: <40 is low (remember this is bad because we want it up), 40-59 is better and >60 is preferred.
  • Triglycerides: > 150 is borderline high, > 200 is high and >400 is very high.

In recent years the decision to call a certain level of cholesterol abnormal has shifted from the levels above to calculated risk from certain factors.  We now rely on calulators which take risk factors into account for the decision on whether or not to treat cholesterol. The calculator I use is based on data published in the article 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. You can access the calculator here.

This calculator will take into account your age, gender, race, cholesterol levels, blood pressure, and presence of smoking and diabetes.  After completing this with your specific values, it will produce a number.  This number is the percent risk of having a heart attack or stroke over the next 10 years.  If this percentage if over 7.5%, then risk is considered high and treatment should be considered.  Sometimes cholesterol that is not considered “high” by the above standards still warrants treatment based on risk.



Treatment:

Initially we try to control high cholesterol without medication.  Below are some ways you can bring your cholesterol down:

  • Maintain a healthy diet by avoiding foods that are high in saturated fats and cholesterol (such as meats and dairy) and trans fats (such as packaged and processed foods and fried foods). Stick to low fat dairy products and increase your fiber intake through roughage, bran and beans.  Lastly, try to increase your fruit and vegetable intake to half of your diet.
  • Keep your weight in a healthy range.  Having a BMI in the overweight or obese categories makes your cholesterol higher.  You can calculate your BMI here.
  • Get enough cardiovascular exercise.  Experts recommend 150 minutes of moderate exercise weekly such as brisk walking or cycling.
  • Stop smoking if you do. If you don’t smoke, don’t start.
  • Limit alcohol intake to 2 drinks a night if male and 1 drink a night if female.  A drink is considered 12 ounces of beer, 5 ounces of wine or 1.5 ounces of hard liquor.

If the above lifestyle modifications are not bringing down the cholesterol into an acceptable range, then medication should be started to reduce the risk of heart attack and stroke.  Common medications are listed below.

  • Statins:  This includes anything ending in -statin with some of the major names like Lipitor, Crestor and Zocor.  Statins work by inhibiting an enzyme in the liver that decreases production of cholesterol and increases LDL removal. Common side effects include muscle aches and elevation of liver enzymes.  The muscle aches can be reduced with the addition of CoEnzyme Q10. You should not eat grapefruit while taking statins because it interacts with them.  Statins are usually the first line medication against cholesterol because there is a direct link between taking them and reducing heart attack and stroke.
  • Bile Acid Sequestrants: These medications include cholestyramine, cholestipol (or anything starting with chole-).  They work by binding to bile which is produced by the liver.  By binding, they make the bile excreted and not reabsorbed into the body.  Bile contains cholesterol and so excreting it instead of absorbing it decreases cholesterol levels. Common side effects include gas, constipation and upset stomach.
  • Niacin: This is a B vitamin which can increase HDL and lower LDL levels by working at tissue and liver sites. Common side effects include flushing and headaches.
  • Fibrates: This includes Tricor, Lopid, fenofibrate and gemfibrozil. It is not completely known how these work but they mainly target triglycerides to bring them down.  Common side effects include liver enzyme elevation and constipation.
  • PCSK9 Inhibitors: This is the newest class of cholesterol medication and includes Praluent and Repatha. They are reserved for when the statins aren’t working and are mainly used in people with a condition called heterozygous familial hypercholesterolemia which is a genetic disorder that causes extreme elevations in cholesterol.  It is an injection given every 2 weeks. Common side effects include skin reactions at the injection site and stomach upset.

I hope this was informative and able to answer any questions you have about high cholesterol.  If you have any further, please comment below. The most important thing when treating any condition including high cholesterol is to establish a trusting relationship with your primary care provider where you are both working together to meet your cholesterol goals and reduce your risk of heart attack and stroke.


Diagnosis Spotlight: High Blood Pressure

Answers to your questions about high blood pressure.

High blood pressure (or Hypertension) is one of the most common diagnoses I see.  It is one I address on a daily basis.  We hear about it all the time but don’t always understand what it is and why it is imperative to get it diagnosed and properly treated.  It’s been called the “silent killer,” but why? In this post I want to take some time to clear up any questions you may have about high blood pressure and impart some ways you can combat it.

What is Hypertension?

Simply put, hypertension is when there is excessive stress or pressure on the arteries in the body. There are two numbers in measuring blood pressure including the upper (systolic) and lower (diastolic) number.   The systolic pressure is the pressure exerted on the vessels when the heart is contracting pushing blood into the arteries.  The diastolic pressure is the relaxing pressure of the arteries caused by the elasticity within the arteries.  Both are important.  A normal blood pressure is under 140/90 when under 60 years of age and under 150/90 when over 60.  There are some conditions where we want to control your blood pressure tighter than this general rule of thumb including when also diagnosed with diabetes, chronic kidney disease and a few other conditions.  Hypertension is called the “silent killer” because it usually has no accompanying signs or symptoms.  The only way to discover it is to have it measured. According to the CDC, about 1 out of every 3 adults has high blood pressure and of these only about half have it under control.

Causes

It is normal for blood pressure to be variable and it can go up and down depending on certain situations.  When it is elevated for an extended period it can be dangerous and increase your risk for heart disease and stroke.  There are two types of hypertension: Primary and Secondary.  Primary or “essential” hypertension is where there is no underlying cause for the increased pressure and secondary hypertension is due to another cause.  About 95% of high blood pressure in the primary care office is primary hypertension.  For this post, we will focus on primary hypertension but if you do have high blood pressure, you should check with your doctor to make sure there is no treatable underlying cause

Risk Factors

There are a few things that can increase your risk for developing hypertension including certain health conditions, lifestyle and family history. The health conditions that can increase your risk include diabetes and prehypertension which is a blood pressure between 120 and 139 systolic and 80 to 89 diastolic.  Lifestyle choices that increase blood pressure include a diet with too much salt, lack of cardiovascular exercise, obesity, alcohol and tobacco use.  There are also things you can’t control that increase your risk including being over 60 and male.


Symptoms

As stated above, there are typically no symptoms with high blood pressure. However, if it is very elevated or goes untreated for a long time, a person can develop symptoms.  If the blood pressure is very high (over 180/110) there is a lot of pressure on the vessels and symptoms can develop including chest pain, headache, vision changes, nausea with vomiting, shortness of breath and passing out.  If these happen with the very elevated pressure, you need to go to an emergency room immediately.  Long term untreated high blood pressure can lead to heart failure (with symptoms of swelling and shortness of breath), stroke, kidney failure and blindness.  If blood pressure is controlled, these can be avoided.

Diagnosis

Diagnosis of hypertension is made by a doctor after elevated blood pressures are found on two separate occasions.  The blood pressure is measured using a sphygmamonometer (say that 10 times fast!) over the upper arm and listening to blood pulsations while slowly decreasing the pressure.  Diagnosis is made based on the numbers in the table below:

Blood Pressure Levels
Normal systolic: less than 120 mmHg
diastolic: less than 80mmHg
At risk (prehypertension) systolic: 120–139 mmHg
diastolic: 80–89 mmHg
High systolic: 140 mmHg or higher
diastolic: 90 mmHg or higher

White Coat hypertension, where the blood pressure is only elevated in the office, is no longer recognized as a true blood pressure issue.  If the blood pressure is elevated in the “stressful” office setting, it is usually going to be elevated in other stressful situations as well and needs to be controlled.  This being said, home blood pressures can be useful.  Here is a link to the home cuff I recommend: Omron 10 Series  (this is an affiliate link where I will receive a small kickback for any purchase).

Once hypertension is diagnosed, there should be blood and urine tests done to look at cholesterol levels, kidney function and an EKG should be done to look for any heart changes.  If the blood pressure is not being controlled with medication, other tests or cardiology referral may be needed.


Treatment

Treatment is initially through lifestyle changes.  This includes combating all of the risk factors stated above.  Thirty minutes of cardiovascular exercise should be done at least 5 days a week.  Proper diet includes adheing to the DASH (dietary approaches to stop hypertension) diet which includes plenty of fruits and vegetables and low salt along with avoid fatty and processed foods.  Men should limit their alcohol to 2 drinks per night and women to 1 drink per night (a “drink” is considered 12 ounces of beer, 8 ounces of wine or 4 ounces of hard liquor). Smoking should be completely stopped because it constricts and damages arteries. If overweight, you should work to lose weight.  Even small amounts of weight loss (5-10 lbs) can affect the blood pressure positively.

If lifestyle modification is not working and the blood pressure remains over 140/90, then medication is needed. Common medications fall into 4 major categories including: diuretics, RAAS (renin-angiotensin-aldosterone system) inhibitors, calcium channel blockers and beta blockers.  All of these can cause low blood pressure, dizziness and fatigue.

  • Diuretics typically include hydrochlorothiazide, chlorthalidone and triamterene and work to reduce the blood pressure by pulling off some fluid in the kidneys.  Common side effects include cramps, electrolyte abnormalities and kidney impairment.  
  • Calcium channel blockers include amlodipine, nifedipine (or anything else ending in -dipine), diltiazem and verapamil.  These work by relaxing the vessels directly and common side effects include constipation, leg swelling and slow heart rate
  • RAAS inhibitors include lisinopril, enalopril (or anything ending in -pril), losartan (or anything ending in -sartan) and aliskiren.  These work by inhibiting a feedback mechanism through the kidney to relax the blood vessels.  Common side effects include cough, elevated potassium, and kidney impairment.
  • Beta blockers include metoprolol, atenolol and anything else ending in -olol. These work by decreasing the rate and contractility of the heart.  Common side effects include slow heart rate, erectile dysfunction and difficulty exercising at higher exertion.
  • There are other medications beyond these but they are reserved for very difficult to control blood pressure.

I hope this was informative and able to answer any questions you have about high blood pressure.  If you have any further, please comment below. The most important thing when treating high blood pressure is to establish a trusting relationship with your primary care provider where you are both working together to meet your blood pressure goals.  

To see my  post on the updated blood pressure guidelines, click here.