I have heard it too many times to count. A patient tells me that one of their healthcare providers ordered a lipid panel and became alarmed when the LDL-cholesterol (LDL-C) was mildly to moderately elevated. Their doctor’s solution? Start on a cholesterol-lowering “statin” drug immediately! Is this this the best solution?

Most Everyone Fails The Test

The American Heart Association tells consumers “to aim for an LDL below 100 mg/dL”. Interestingly, the average LDL-C level in the U.S. is 111.7 mg/dL.  This data comes from a recent study published in the Journal of the American Heart Association and involved about 51,000 U.S. patients. This data tells us that most U.S. adults will show an elevated LDL-C level and have it flagged as elevated on their lab results. As a result, statin drugs are being prescribed like never before.

Is LDL-C Evil?

If you believe the body is the result of random processes over time, then believing LDL-C is evil makes sense. However, if you look at the body as having a sophisticated design and function, then the well-known scientific fact that LDL-C serves many vital functions in the body should not be a surprise. It is well known that LD-C is involved with:

1. Cholesterol Transport

• LDL carries cholesterol and phospholipids from the liver to peripheral tissues, which are needed for various functions, such as cellular repair and other activities.

2. Cell Membrane Synthesis

• Cholesterol delivered by LDL is incorporated into cell membranes, maintaining their fluidity and stability, which is essential for proper cellular function. In addition, cholesterol is used for the formation of lipid rafts in cell membranes, which play a role in cellular signaling, energy storage, and protection of cells against temperature extremes.

3. Hormone Production

• LDL cholesterol is a precursor for steroid hormones, including sex hormones (e.g., estrogen, testosterone), adrenal hormones (e.g., cortisol), and others necessary for metabolic regulation.

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Challenge Everything

I recently saw an article by a cardiologist who stated that those who deny the importance of lowering LDL-C are “science deniers.” It wasn’t too long ago that a certain pandemic occurred where many “science deniers” ended up being correct about many things the “experts” had mandated. Perhaps this cardiologist would be considered a “science denier” based on the recent study I will review.

Eye Opening Study

A recent study in the mainstream BMJ Open titled: Is LDL cholesterol associated with long-term mortality among primary prevention adults? A retrospective cohort study from a large healthcare system was published. This study analyzed data in adults (aged 50-89) who were generally healthy and without diabetes and not on statin therapy and all-cause mortality (death). Approximately 180,000 patients with a mean age of 61 and a mean LDL-C of 119 mg/dL were evaluated over 6.1 years. Interestingly, the authors found that the lowest risk for long-term mortality was in those with an LDL-C range of 100-189 mg/dL. In their introduction, the authors stated”: “Despite the generally accepted belief that ‘lower LDL-C is better,’ meta-analyses indicate that high LDL-C is associated with at most a small increased absolute risk of ASCVD or premature mortality.” The authors noted the evidence that goes against the prevailing recommendation that lowering LDL-C should be the focus for preventing heart disease:

1. A recent meta-analysis (2023) involving 60 randomized controlled trials found that the number needed to reduce one death in treating patients with more potent lipid-lowering therapy was very high at 754 persons. Moreover, there was no relationship between LDL-C percent lowering and risk of cardiovascular mortality.
2. Acute coronary syndrome (reduced blood flow to the heart usually due to plaque build-up causing chest pain and other symptoms) is routinely normal in patients with a normal LDL-C. Also, women generally have a lower risk of coronary heart disease but tend to have higher LDL-C.
3. Robust life insurance data has found the total cholesterol to HDL-cholesterol ratio to be a better measure of all-cause mortality than LDL-C.

When In Doubt Image

I am always surprised at how many patients I talk to who have mild to moderately elevated LDL-C levels, who are recommended drug therapy, and who have not had any heart imaging.  Imbalanced cholesterol levels are only problematic if one is forming plaque in the arteries! Even the American College of Cardiology states that Coronary Artery Calcium (CAC) testing can help one decide if they need statin therapy. A coronary artery calcium test is a type of x-ray (CT) that detects and quantifies calcium in the walls of the heart (coronary) arteries. The amount of calcification represents hard plaque in the arteries. A score of 0 or a low score means that people without diabetes or heart disease do not need aggressive drug therapy.

 0: No calcium detected, very low risk of heart disease.

  1-99: Small amount of calcium, mild heart disease risk.

 100-399: Moderate calcium levels, moderate risk of heart disease.

400+: High amount of calcium, high risk of heart disease and potential for a heart attack.

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A more extensive version of the CAC is the coronary computed tomography angiography (CCTA) with Cleerly technology. This imaging also used a CT scan and contrast dye to generate detailed 3D images of the heart arteries. Using the Cleerly AI technology, one can see and quantify the hard plaque and more dangerous soft plaque in the arteries. I use these imaging tests with patients to further clarify what a patient’s actual risk of heart disease is and what type of care they need for the prevention and treatment of heart disease.

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Conclusion

There are many factors involved with cardiovascular risk. These risks include diet, lifestyle, weight, diabetes, stress, toxins, genetics, and other factors. An elevation of LDL-C is one of many potential risk factors for cardiovascular disease. If you do not have diabetes or cardiovascular disease, the use of drugs for LDL-C lowering seems to be overprescribed. It is always best to address the root causes of cardiovascular disease and the use of nutritional supplements to balance various lipids. The use of imaging helps to clarify those who do need more aggressive drug therapy.

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References

Gao, Y., Shah, L. M., Ding, J., & Martin, S. S. (2023). US Trends in Cholesterol Screening, Lipid Levels, and Lipid-Lowering Medication Use in US Adults, 1999 to 2018. Journal of the American Heart Association, 12(3), e028205. https://doi.org/10.1161/JAHA.122.028205

Kip, K. E., Diamond, D., Mulukutla, S., & Marroquin, O. C. (2024). Is LDL cholesterol associated with long-term mortality among primary prevention adults? A retrospective cohort study from a large healthcare system. BMJ Open, 14(3). https://doi.org/10.1136/bmjopen-2023-077949

What your cholesterol levels mean. www.heart.org. (2024, June 17). https://www.heart.org/en/health-topics/cholesterol/about-cholesterol/what-your-cholesterol-levels-mean 

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