Cholesterol Confusion

Change can cause confusion, especially with how many factors relate to cholesterol management and plaque buildup.

Medical innovation and clinical trials are helping to fuel adjustments to cholesterol management in pursuit of saving lives.

Heart attacks and strokes are directly related to a buildup of plaque in the inner walls of arteries, which is caused by the accumulation of fat, cholesterol and other substances.

The cholesterol guidelines were revised in 2013 and then again in 2018 by the American College of Cardiology.

Broadly speaking, changes in the cholesterol guidelines have focused on calcium measurement testing, statin usage, and early intervention. Due to the extent of the cholesterol guideline changes, statin usage will be covered in the blog All About Statins and early intervention will be covered in the blog Kids and Cholesterol.

What has NOT changed over time.
Some health recommendations have stayed a constant, such as life-style intervention.

“When it comes to diet, we’ve known the right approach for thousands of years,” USF Health Cardiologist Dr. Bibhu Mohanty said. “It has just become more difficult to manage in the face of a rapidly developing food industry the last 50 years – sometimes compromising quality and healthfulness for convenience. The good news is, over the last 10 years, we’ve really come around to seeing some of the errors we’ve made as a society, and building a healthy lifestyle is really at the forefront of people’s minds.”

Discover a few of Dr. Mohanty’s suggestions for building a healthy lifestyle:

  • Embracing an active lifestyle and exercising
  • Eating a healthy heart diet, rich in fiber, fruits/vegetables, and limiting simple sugars
  • Maintaining a healthy weight
  • No smoking

Know your Risk Score (ASCVD)
The 2018 Cholesterol Guidelines detail a shift to risk assessment through the ASCVD (Atherosclerotic Cardiovascular Disease) Risk Score versus just focusing on cholesterol numbers. It starts by determining a patient’s total cholesterol. A fasting blood test is performed to assess the concentration of several types of cholesterol in the blood, as well as fat content. The conventional cholesterol test gives you four results:

  • Total cholesterol
  • LDL (bad) cholesterol
  • HDL (good) cholesterol
  • Triglycerides (blood fats).

The results from the blood test are then combined with other factors including age, race, systolic blood pressure, treatment for hypertension, treatment with statins, diabetes status, aspirin therapy and smoking status. This combined will generate an ASCVD (Atherosclerotic Cardiovascular Disease) Risk Score. This score is a patient-specific percentage risk of developing heart attack or stroke over 10 years, and patients are treated based on categorization of this risk.

Cholesterol Testing – Calcium Measurement
When a patient falls into an intermediate risk zone, the 2018 Cholesterol Guidelines encourage cardiologists to have a thorough conversation with patients about potential benefits of statin drugs, taking into account all the risk factors. If uncertainty remains about whether to prescribe a statin, cardiologists can consider further testing.

The CAC (Coronary Artery Calcium) test is a CT scan that reports the amount of calcium in your coronary arteries. “The only way calcium can develop in the coronary arteries is by maturation of long-standing cholesterol plaque,” Dr. Mohanty said. If there is calcium present, there must be cholesterol plaque present. “Not all plaque is calcified, but based on the overall population, the degree of calcium correlates with the overall accumulation of plaque during a patient’s lifetime.”

We all have plaque and as we age, we will develop calcification of that plaque in our arteries. The calcium score is essentially calibrated based on a patients demographic features, most notably age. Every age group has a normal distribution of calcium in the arteries, so the score reflects the percentile rank for a patient compared to his/her age cohort, and this is used to inform risk. Cardiologists provide this information during their discussion with patients about starting therapy.

If it is felt that the coronary calcium accumulation is concerning in conjunction with other risk factors, statin therapy will typically be prescribed to stabilize plaque and reduce long term risk. If the CAC test result is zero and the patient does not smoke or have other risk factors such as diabetes or a family history of early heart disease, then the decision could be jointly made to not start statins therapy for the time being.

“Understanding cardiovascular risk can be complicated, but it is important to discuss with your cardiologist how to best manage risk over an extended period of time,” Dr. Mohanty said.

To find out more about the cholesterol guidelines revised in 2018, read Kids and High Cholesterol and All About Statins.

We are excited to share, our Cardiology department is expanding!  Dr. Jennifer Bennett, Dr. Patrick Chang, and Dr. Rachel Harris are accepting new patients. Learn more about cholesterol and get to know Dr. Jennifer Bennett and Dr. Patrick Chang from USF Health Minute.

To make an appointment with USF Health Cardiology, call (813) 259-0600.

Written By: Kathleen Rogers

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