Dyslipidemia

Posted on August 10, 2016 | Posted by

We purposely don’t say “high cholesterol”. The three categories of cholesterol particles are LDL, HDL, and triglycerides. LDL and triglyceride particles cross through an inflamed, dysfunctional endothelium to form plaque. HDL transports LDL and triglyceride out of plaque into the bloodstream. It is a process called “reverse cholesterol transport” and can cause plaque to get smaller.

There are several different subtypes of LDL, HDL, and triglyceride particles, each one having a different risk of forming plaque. Inflammation and insulin resistance will change the mix of particles, increasing ones that are atherogenic (plaque forming). Exercise and medications can improve the mix.

The good guy- HDL

HDL cholesterol is very important because it drives “reverse cholesterol transport.” Think of this as HDL shoveling cholesterol out of plaque back into the bloodstream.

  • Every 1 point HDL increases results in a 1.9% decrease in stroke risk and up to a 6% decrease in heart attack risk.
  • Low HDL is the abnormal lipid most predictive of strokes.
  • Large HDL particles are the “superheros” of the good guys and should be measured.
  • Low HDL is associated with memory loss. This is not surprising since a common cause of dementia is multi infarct dementia from tiny clots showered to the brain over many years from diseased carotid arteries.

The bad guys- LDL and triglycerides

Quantity is important

We are finding that total LDL cholesterol is less important than we used to think. In your evaluation, we do not even list your total LDL cholesterol value. We will monitor the following lipid values:

  • Lipoprotein(a)- (goal <75) The amount of this small LDL particle is genetically determined. Lifestyle changes don’t help. Only niacin may lower it, but it is a weak effect. When elevated, we will treat other risks more aggressively, especially if plaque is already present.
  • Total cholesterol/HDL ratio- (goal<2.8) The best predictor of vascular disease.
  • APO B- (goal< 60) a measure of the most dangerous particles. It is a better predictor of vascular risk than LDL and is the best test to follow the effectiveness of a statin.

 

Quality is important

LDL1 and LDL2 are large particle sizes; LDL3 and LDL4 are small particle sizes.

We measure LDL particle sizes. The medics will help determine treatment if medication or supplements are needed.

 

Treatment

The most important treatment of dyslipidemia is to treat the insulin resistance and inflammation that cause many of the abnormalities.

  • Statins- Although they can dramatically improve cholesterol, their biggest benefit is to reduce vascular inflammation and stabilize the vessel endothelium. Some also improve insulin resistance.
  • Niacin- Complements a statin in many ways.
  • Alcohol- Moderate consumption is helpful only if you are not the APOE4 genotype. Moderate consumption is defined as: women- 1 drink daily, men-1-2 drinks daily.
  • Cranberry juice- 8 ounces (one cup) of 27% pure juice daily raises HDL.
  • L-carnitine- 2 gms daily combined with a statin may lower lipoprotein(a).

 

Are statins safe?

Statins significantly reduce your risk of heart attack and stroke if you have a vulnerable plaque.

Whether or not statins are safe is ongoing debate. Statin medications deplete coenzyme Q10 so can theoretically affect your muscles, especially at higher doses.

Your assessment will help determine whether its benefit is worth the possible risk.

Supplementation is wise when a statin is needed.