New Cholesterol Guidelines

Back in November 2013, the American Heart Association issued new cholesterol guidelines that immediately created confusion and controversy for both patients and physicians. The committee reviewed many randomized controlled clinical trials that lead to the development of a risk calculator. Factors such as sex, age, race, total cholesterol, HDL ("good cholesterol"), systolic blood pressure, treatment for elevated blood pressure, diabetes and smoking are used to generate a 10 year risk number. If that number is greater than 7.5%, then the use of a statin is recommended. This is regardless of the level of  your LDL cholesterol ("bad cholesterol").  In the past, target levels of total cholesterol, HDL and LDL cholesterol were the major parameters used. The committee also announced that life style modification is the  first line of treatment but also stated that no other drugs, supplements or vitamins should be used, just a statin. In addition, 3 groups of patients didn't need to use a calculator, they are automatically advised to be on a statin. These patients are those who already have coronary artery disease, patients whose LDL cholesterol is 190 or above and patients who are diabetic.  Some predict that these guidelines will undergo revision and in fact, The United States Preventative Health Task Force is working on its own set of guidelines to be issued within 2 years. So, let me take this opportunity to tell you how I treat patients with elevated cholesterol. First of all, it is important to understand that coronary artery disease is not simply a disease of too much cholesterol like sludge clogging a pipe.   For over 20 years medical science has understood that arteriosclerosis is primarily an inflammatory process and a process of injury to the lining of arteries. This injury can be related to bacteria, hormones that constrict blood vessels, abnormal levels of LDL cholesterol, an entire cascade of inflammatory chemicals from fat tissue, and increased stickiness of white blood cells. The plaque that blocks the artery is not the problem, it is the result of the body's reaction to the problem. Further, it is important to understand that modern medicine uses primarily a statistical model of therapeutics basing recommendations of the "average" patient. I prefer to use an individual approach since we now have tests for various components of the plaque problem. I test for inflammatory markers such as cardiac specific C- reactive protein (CRP) and homocysteine (a risk factor for coronary artery disease) as well as total cholesterol, HDL cholesterol and LDL cholesterol. . I agree that if a patient already has a history of blockages in the heart arteries and/or a history of previous heart attack,then he or she should be on a statin.  The presence of elevated cholesterol does not mean that it is deposited in the coronary arteries. I often order a calcium scoring of the coronary arteries. This is essentially a CT scan of the arteries looking for the amount of calcium in the arteries (plaque contains some calcium). It does involve radiation, however, the scan doesn't need to be done very often, maybe once or twice in a lifetime if the score is low. It is true that one can approximate the degree of plaque in the heart arteries by getting an ultrasound of the carotid arteries but the CT scan also provides some information about the aorta and the lung fields and I believe that it is generally worth the risk. If the calcium score is zero or low, and the CRP and homocysteine levels are low, then a stain is usually not needed and life-time risk for coronary artery disease can be calculated from the calcium score.

If plaque is found on the scan and if the patient has other risk factors such as family history or diabetes, then homeopathy can be used to reduce the amount of a statin that is needed. This can be done with  life style modification, a general constitutional remedy or the use of homeopathic tinctures made from herbs known to lower cholesterol. Cholesterol can also be lowered by the use of krill oil and triglyceride levels can be lowered by the use of fish oil.  Osteopathy can play a roll in this condition by treating the liver directly with visceral manipulation and by treating parts of  thoracic spine related to the function of the liver and gallbladder. Generally, my approach is to use technology to help individualize the treatment of this condition with a minimum of conventional medication.