Why I'm aggressive about my cholesterol

Cholesterol deposition in an artery

As I mentioned in my last post, I decided to lower my cholesterol even with a calcium score of zero. Over the years, I have become more aggressive about lowering my LDL (and ApoB). Here are 3 reasons why:

1. LDL plays a causal role in heart disease and stroke. The causal relationship is supported by multiple lines of evidence, including epidemiological studies, genetic studies, and randomized clinical trials. If we agree that LDL is causing coronary artery disease, then why should we tolerate an elevated LDL? I agree with Peter Attia’s analogy to smoking and its causal role in lung cancer. We don’t tell patients that smoking 10 cigarettes daily is risky, but 5 cigarettes daily is tolerable. All doses of smoking increase risk of heart disease. I feel the same about LDL.

2. It’s an area under the curve problem. A small elevation in LDL over decades becomes a huge problem. Higher LDL for longer time is more opportunity for cholesterol deposition and plaque build up in the coronary arteries. Conversely, a lower LDL level over a decades protects against coronary artery disease. A 15-year prospective study looked at people born with a genetic mutation (PCSK9 mutation) that resulted in a lower LDL cholesterol over their entire lifetime. These individuals had an average LDL cholesterol of 100 mg/dl resulting in an 88% reduction of heart disease compared to those without the mutation that had average LDL cholesterol of 140 mg/dl. The authors conclude, “These data suggest that relatively moderate reductions in LDL cholesterol level (20 to 40 mg/dl would markedly reduce the incidence of CHD in the population if sustained over a lifetime.” Why wait until I’m 60 to start lowering my LDL?

3. Low LDL does not cause problems. Healthy infants have LDL levels around 40-60 mg/dl and have perfectly normal growth and development. There are individuals who are homozygous for a loss of function mutation in PCSK9 that have lifetime LDL levels of 20-30mg/dl with no significant adverse consequences, including no increase in rates of dementia (more on this in a subsequent post). In fact, quite the opposite: these individuals have extremely low rates of heart disease and stroke.

For these reasons, I decided to be proactive about lowering my LDL. I always start with lifestyle first. I was already eating a healthy diet, doing both resistance training and aerobic exercise, not a smoker or diabetic, yet my LDL was still 130-140 mg/dl. I cut out red meat and dairy and increased my fiber intake for 6 weeks and my LDL only dropped 5 points. It seems my genetic set point for LDL was about 130 mg/dl. We may all have a genetic set point for our LDL. This is the level of LDL our body produces with optimal lifestyle choices. Poor lifestyle choices can make it higher, but good lifestyle choices do not seem to make it much lower. For me, that meant starting a medication.

Like millions of Americans, I started taking a statin (10 mg of atorvastatin). My LDL dropped to 100 mg/dl and I have not experienced any adverse effects. The guidelines at that time suggested that an LDL of 100 mg/dl was reasonable. However, new reasoning suggests “lower is better.” After learning about the PCSK9 story and those individuals with genetic mutations resulting in low LDL levels throughout their entire life without adverse consequences, I have decided to aim for an LDL of 70 mg/dl. This means increasing my statin dose as long as my body can tolerate it without adverse effects.

The decision to take a cholesterol lowering medication is a highly personal one. It has a lot to do with one’s risk tolerance. The risk of a heart attack or stroke must be weighed against the risk of the medication. For some, a low 10 year risk of heart disease is sufficient reason to not start a medication. Risk can be re-evaluated over time and when that risk reaches a certain threshold, medication can be started. This is a personal choice.

I view the lowering of LDL over a long period of time as analogous to saving up for retirement. A small amount of money saved up each year adds up to a large amount of savings after a few decades. As the evidence shows, a lower LDL (or ApoB) over decades results in a large decrease in the risk of a heart attack or stroke. Given that heart disease remains the number one cause of death globally, I think lowering LDL is a good investment in your health.