People compete in a lot of areas – including their cholesterol levels. Cardiologists are just as likely as their patients to play the game of “My LDL is lower than yours.” The reasons to be proud of a low number make perfect sense:
· Dozens of research studies show that reducing levels of low density lipoprotein (LDL) cholesterol lowers risk for heart attacks
· For high risk patients, such as people who have just been hospitalized for severe angina or a heart attack, going from low LDL levels (less than 100 mg/dL) to very low levels (70 mg/dL or less) provides added benefit
Lowering LDL cholesterol is pretty painless, since statins like Lipitor (atorvastatin) and generic simvastatin are highly effective and have a low incidence of significant side effects.
If low LDL levels are good, and very low levels are even better for high risk patients, why not go for very low levels in everyone? Why stop at 70 mg/dL? Why not reduce LDL levels to 50? 30?
Three questions give experts pause when they contemplate a world in which everyone takes statins and everyone has very low LDL levels. These questions are:
- Do higher doses of statins lead to higher side effect rates?
- Do very low LDL levels increase a person’s risk for cancer?
- Are there benefits associated with very low cholesterol levels that justify the expense?
1. Do higher statin doses lead to higher side effect rates?
The most common side effects of the statins are damage to the liver and muscles. U.S. physicians tend to ask patients on statins to come back every six months for blood tests in order to check for these side effects. In truth, these problems occur so rarely that physicians in many countries do not routinely test patients’ blood to screen for these complications.
The question of whether high statin doses lead to higher rates of side effects was recently addressed in a study published in the Journal of American College of Cardiology that pooled data from 23 separate research trials. The results? Higher statin doses were associated with higher complication rates. For example, patients who took low doses of a statin (e.g., atorvastatin 10 mg or simvastatin 20 mg per day) developed liver problems at a rate of 1 out of every 1,000 patients per year. But those on higher doses (e.g., 80 mg of atorvastatin or simvastatin) had a rate about 2.5 times higher. That said, the side effect rates were quite low, even with high dose statin therapy.
2. Do very low LDL levels increase cancer risk?
On this issue, the data are murkier. On one hand, the study found no evidence that patients taking higher statin doses had higher rates of cancer. However, there was a trend toward higher rates of newly diagnosed cancer in patients whose LDL levels were lower. The researchers didn’t feel that their data proved that very low LDL levels cause cancer. But they and the journal editors agreed that the findings warranted more research. No one knows at this point if statins cause cancer, or how these drugs might do so. That said, we know statins have a wide range of effects besides lowering cholesterol, and that cholesterol has many roles besides causing heart disease.
3. Are there benefits associated with very low cholesterol levels that justify the expense?
For people with a high risk for heart problems – like those who have just survived a severe episode of heart disease – the benefits of aggressively pursuing LDL cholesterol levels under 100 mg/dL and all the way down to 70 mg/dL are worthwhile. But for people with a lower risk for heart attacks – such as those who do not have any known heart disease, and just have high cholesterol levels – the benefits of going all the way down to 70 mg/dL are trivial.
Yet the costs required to get to very low levels of LDL are not trivial. These costs are financial – higher doses of statins are likely to cost more both to the patient and the insurance company. And these costs can also come in the form of higher side effect rates.
Even if the possible increased risk of cancer with very low LDL levels does not pan out with future research, the case for going for LDL levels well under 100 mg/dL for most people is not compelling.
What is the LDL cholesterol goal that you and your doctor set? Do you think it should be lower?
Thomas H. Lee, M.D., is an internist and cardiologist who is a Professor of Medicine at Harvard Medical School. He is also the Network President of Partners Healthcare System, the integrated delivery system founded by Brigham and Women's Hospital and Massachusetts General Hospital.
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Comments: 11
You have to call back and get a little more information. If the 133 is the reading for your total cholesterol, that really is terrific. Total cholesterol includes the "bad" (LDL), the "good" (HDL), and the cholesterol that is part of fats (triglycerides) in your blood. But if the reading is for your LDL cholesterol, 133 is pretty average, and I would be encouraging you to lower the fat in your diet, exercise more, and possibly lose some weight.
Tough to comment without knowing the readings for your HDL and LDL cholesterol levels. In general, the goal is to get your LDL under 100. If you have known heart disease, or other evidence of atherosclerosis, most of my colleagues and I push for a lower LDL level, like 70. You should ask your doctor for the breakdown of HDL and LDL levels.
I would like to more about what those benefits for diabetics might be.
Thanks for responding to my question. I will call them to get the actual result. My Hubby and I have been cutting a lot of the fat from our diet and are working on losing some weight. In the last 2 years, I've lost 30 lbs on Weight Watchers and do walk (when the temps aren't in the 100's).
Thanks again for the information.
I am going to make the assumption that we are talking about your LDL cholesterol level, which I think is pretty likely. (I do think your doctor should tell you if that is the case.) If I am correct, you have pretty good LDL control, and that's actually great news. People with diabetes have a pretty high risk for developing atherosclerosis and diseases like heart attacks and strokes. Diabetics benefit a lot from taking statins, so I think you should stay on this. Make sure you are getting the generic, because it will cost you less, and you are highly likely to be on a statin for the foreseeable future.
Wow – your LDL is really quite low, reflecting the fact that Crestor (rosuvastatin) is the most powerful cholesterol lowering drug. Since people with diabetes have a pretty high risk of having heart disease, and because statins lower the risk of a heart attack by about one-third, you really do stand to benefit quite a bit from taking a statin – even if your LDL was low to begin with. So I would stay with a statin. You may not need quite so dramatic LDL reduction, and if you were to develop side effects like muscle aches, I would try a low dose of a weaker statin.
My cholesterol is low, just plain low: Chinese MD's (Asian trained and acupunturists from china) get concerned about low cholesterol. But not the USA MD's - they tend to tell me that only High Cholesterol is villanoous. Really? And please, why is that? People have wanted to know. :D
Thanks,
Alex