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Cholesterol

4,638 Views | 34 Replies | Last: 1 yr ago by lazuras_dc
RightWingConspirator
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AG
Guys, I just got my numbers back from my annual blood exam. My A1C came in at 4.7 this time, which I was very pleased with. I realize that many have differing views on this level of A1C, but I'm pleased with it as I've alleviated many of the lows with which I was struggling.

My blood numbers are as follows:

- Total Cholesterol 229
- LDL 172
- HDL 66
- Triglycerides 42

I'm aware that many doctors from around the world have differing views on cholesterol. My doctor is wanting to put me on a statin now, but I'm not convinced it is needed just yet. I'm open to it, but I'd like to better understand whether I have a real issue that needs addressing. There is much out there on dietary cholesterol not being the bogeyman people think it is, etc. There are also many European doctors that also feel cholesterol is not as big of an issue that we make it out to be as well.

My question for you is, what are your thoughts on my numbers. (Let's keep the discussion away from A1C). Does your doctor have unorthodox views? Should I be concerned in your estimation?

As a reminder, I'm a Type 1 Diabetic and have had the disease for 35 years. I'm on a high fat / high protein low carb diet and have been now for the better part of the last 15 years. I lift 5 nights a week and I'm 6"1' and 183 pounds of lean muscle and little body fat.

What say you?

"But it is easier to purchase products that denote superiority than to be actually superior in economic achievement." - Thomas J. Stanley
JHUAggie
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You can plug your numbers into the ASCVD calculator and find out for yourself.

If your 10 year risk is greater than 10% then you should be on a statin. Less than 7.5% then no statin. In between 7.5% and 10% its your call.

However, I do not like your LDL at 172. Your HDL is normal which helps lower your risk.
RightWingConspirator
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AG
Mine came in at 3.5%.

What's weird is the my total cholesterol does not add up correctly with my LDL and my HDL. If I assume the LDL is correct, my total would be 238 and not 229. At that, my score comes in at 3.5. If I assume the LDL is off and my Total is correct, it comes in at 3.3%.

Either way, the score seems low to me. Reading about some of the horrible side effects of Lipitor that people experience, I'm inclined to not risk mobility and comfort for something that appears to be low risk as of right now.
"But it is easier to purchase products that denote superiority than to be actually superior in economic achievement." - Thomas J. Stanley
JHUAggie
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You must be young. If your risk is at 3.5% then I wouldn't recommend a statin either. I edited my initial response.

Just realize as you get older that percentage will continue to climb upward even if your cholesterol numbers stay the same or get slight better.
RightWingConspirator
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I'm 46. Going to be 47 here in a few weeks.
"But it is easier to purchase products that denote superiority than to be actually superior in economic achievement." - Thomas J. Stanley
OasisMan
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im a stroke neurologist, but not a big fan of statins



bigtruckguy3500
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LDL is calculated in most commercial cholesterol tests, it isn't actually measured. Plus there are additional lipoproteins, such VLDL, that are present in the blood. Furthermore, there are multiple subtypes of LDL, with some being more prone to causing atherosclerosis than others. There is a graph I saw years ago that showed the correlations between LDL, HDL, and heart attacks. The bottom line of the graph was that the high the LDL, the higher your chance of heart attack, with a very strong correlation. However, that was with low HDL. When HDL increased, the correlation began to diminish, and high LDL was no longer as predictive of cardiac risk. So basically, the numbers from a regular cholesterol test are a good screening tool for most of the population, but doesn't tell the whole story.

There's also some thought that other things like high blood pressure and inflammation in the body can play a large role in determining to what extent your cholesterol affects your risk for atherosclerosis. There are some other biomarkers, I think homocysteine might be one, that correlates well with risk of atherosclerosis.

I'm pretty skeptical of statins. I actually think the number needed to treat is much higher. Statin manufacturers often tout relative risk reduction instead of absolut risk reduction. What this means is that, as an example, if I gave a drug to 100,000 people and it reduced heart attacks by 50%, it would look like an amazing drug. But what if I were to tell you that in actuality that it only reduced the heartattacks from 0.1% to 0.05%, or 100 people to 50 people. Suddenly doesn't seem as impressive, at least to me. What if I further told you that of those 100,000 on the drug, 50 might have seen a benefit, but 1000 saw clinically significant side effects. I'm just making up numbers, but you get my point.
ramblin_ag02
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AG
You're going to catch a lot of info out there about cholesterol and statins and the like. The main thing that jumps out to me is that you say you have Type 1 Diabetes. That's a really big risk factor for heart attack and stroke all by itself. The calculator may ask if you have diabetes, but there is a big difference between a Type 2 diabetic diagnosed at age 40 and a type 1 diagnosed at age 10. I'd lean heavily on the expertise of my primary physician or endocrinologist (if you have one). With something like type 1 diabetes, the rules of the game are so different that most of our studies just don't apply
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
RightWingConspirator
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Ramblin Ag, the calculator did ask me if I was diabetic, but don't remember if it asked me about type 1 or 2.

In my defense, I'd say I'm not your typical diabetic. For the last 15 years, my highest A1C was 5.3, and that happened only once. Most of the time, my A1Cs come in at the 4.7-4.8 range.

Now, I understand A1C is not perfect, but I could back the A1C results with actual blood sugar readings. Before I got on the Dexcom, I would check sugar 7-8 times per day.

I'll continue to research, but right now I'm inclined to not take a statin. A doctor whom I have great respect for also mentioned what BigTruck 3500 wrote, and that was inflammation was a far more predictive measure. In fact, as a Diabetes expert, he was saying he does not even test his patients' cholesterol at all finding it completely irrelevant as a predictor of heart disease.
"But it is easier to purchase products that denote superiority than to be actually superior in economic achievement." - Thomas J. Stanley
ramblin_ag02
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Yeah, I'm not trying to advise for or against statins for you. Just that your situation is more unique than most, and that's where having a doctor who knows everything about you specifically is key
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
RightWingConspirator
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Thanks for the responses, guys. I appreciate it.
"But it is easier to purchase products that denote superiority than to be actually superior in economic achievement." - Thomas J. Stanley
cjsag94
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AG
How is inflammation in the body measured or monitored.. and treated?
OasisMan
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AG
cjsag94 said:

How is inflammation in the body measured or monitored.. and treated?
several non specific serum biomarkers

Crp is a common one
cjsag94
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AG
I'm going in for a physical in a week... Always have high cholesterol, and have refused statins based on always seeing most of what I've read in this thread.

As part of my physical, is this (CRP reading) something I can ask for as part of the blood work being done?
Na Zdraví 87
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AG
I cannot take statins. If I take just one, my legs feel like someone beat them with a baseball bat.
I take a combination of what my dr calls old school cholesterol rx. Seems to work fine.
I'm going to ask my cardiologist about the repatha injection for cholesterol.
Anyone on it/tried it?
Dad
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AG
If I was the OP I wouldn't take them either.

I don't think the benefit outweighs the risks.

I'm always amazed by these type 1 diabetics that are able to control the disease so well. I have family members that are type 2 diabetics that think you can just keep eating whatever you want and not exercising and everything is okay as long as you take the pills the doctor prescribes. Some say they "watch what they eat" but it still seems to be the same crap.
RightWingConspirator
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Aggiemaster, I'm very disciplined in what I eat and I never skip workouts. High for me is 120. My body reacts at 120 like most diabetics react at 300. It works for me.
"But it is easier to purchase products that denote superiority than to be actually superior in economic achievement." - Thomas J. Stanley
OasisMan
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cjsag94 said:

I'm going in for a physical in a week... Always have high cholesterol, and have refused statins based on always seeing most of what I've read in this thread.

As part of my physical, is this (CRP reading) something I can ask for as part of the blood work being done?
yes
AggieEE2002
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AG
Apologies for bumping a three year old thread, but I'm in a quite similar boat and this popped up in a search.

T1D here, 41 years old.

Most recent lipid panel:
  • Total cholesterol: 195
  • HDL: 72
  • LDL: 109
  • Triglycerides: 71

While my A1c isn't quite as good as the OP (4.8% - damn that's impressive!!), my number has averaged 5.1% over the last two years. I'm also a Dexcom user. Diet is pretty good and I work out 4-5 days a week. I probably eat too many eggs.

At my previous appointment with my endo she suggested starting on a statin - 20mg Atorvastatin (generic Lipitor it looks like), and she brought it up again today. She based this on the ADA guidance for all diabetics, regardless of cholesterol level. She said obviously that guideline covers a very large range of people and circumstances, but that even though my control is better than average the benefit of the statins was a reduction in inflammation caused by high blood sugars.

In general, I'd like to avoid taking a pill with potential side effects for the rest of my life if I don't have to, and I'm not sure the risk/reward is worth it in my particular situation. At least not yet. But I'm really struggling to find good information to help me make a decision on this. The only reason she is recommending the statin is because I check the 'diabetic' box - the lipid numbers by themselves don't warrant it.

Curious if the OP or anyone else in this original thread has any additional information or thoughts from the few years since this was originally posted?
Na Zdraví 87
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Good luck on the statins if you decide to go that way. I can't take them. My legs hurt like crazy if I take one pill. I'm off the cholesterol meds now as I lost weight, exercise and eat good. I also stopped drinking alcohol due to blood pressure issues and for other health reasons.
KidDoc
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I'm 49 overweight and on 10mg atorvastatin for a few years. Zero side effects for me.

My bmi was 34ish when I started and LDL 180s and HDL 60s. I'm down to 30 bmi now and my last LDL was 85 and HDL 89! The weight loss achieved with the miracle drug (for me) Wegovy.

If you were my kid or friend I would tell you to try a statin. If you get side effects then stop it. If you don't have side effects see how your numbers look in three months.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
OasisMan
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AggieEE2002 said:

Curious if the OP or anyone else in this original thread has any additional information or thoughts from the few years since this was originally posted?
check out your 10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk
-- this was the 2013 guide for placing people such as yourself on "primary prevention" -- ie statin therapy before something happens


as mentioned before, im not a big fan of statins, which i do catch flack for being a stroke neurologist -- however, as i pointed out, the evidence is weak --> well it turns out that it is even weaker than I had thought !


a study was just released in JAMA this week -- Evaluating the Association Between Low-Density Lipoprotein Cholesterol Reduction and Relative and Absolute Effects of Statin Treatment -- the "key points"
Quote:

Question: What is the association between statin-induced reductions in low-density lipoprotein cholesterol (LDL-C) levels and the absolute and relative reductions in individual clinical outcomes, such as all-cause mortality, myocardial infarction, or stroke?

Findings: In this meta-analysis of 21 randomized clinical trials in primary and secondary prevention that examined the efficacy of statins in reducing total mortality and cardiovascular outcomes, there was significant heterogeneity but also reductions in the absolute risk of 0.8% for all-cause mortality, 1.3% for myocardial infarction, and 0.4% for stroke in those randomized to treatment with statins compared with control, with relative risk reductions of 9%, 29%, and 14%, respectively. A meta-regression was inconclusive regarding the association between the magnitude of statin-induced LDL-C reduction and all-cause mortality, myocardial infarction, or stroke.

Meaning: The study results suggest that the absolute benefits of statins are modest, may not be strongly mediated through the degree of LDL-C reduction, and should be communicated to patients as part of informed clinical decision-making as well as to inform clinical guidelines and policy.

i have recently been putting people on Leqvio (inclisiran) -- its an injection given every 6mo
Quote:

New post-hoc analysis demonstrates 99% of patients treated with inclisiran showed placebo-adjusted reduction in low-density lipoprotein cholesterol (LDL-C) of 30% with a mean reduction of 54.1% from baseline (observed values).
now, Novartis is quick to point out "It is not known if LEQVIO can decrease problems related to high levels of bad cholesterol, such as heart attacks or stroke."


*disclaimer - i dont know you or your data and this is not a recommendation, rather information


RightWingConspirator
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AG
My thoughts are still the same. Last time they ran labs, this is what it looked like:

Total Cholesterol - 243
Triglycerides - 62
HDL - 63
CRP - 0.3
A1C - 4.8
BMI - 24.1 (lift weights 5x per week so have little body fat and a lot of muscle)

Still not on a statin and its doubtful anything will change my mind.

Any thoughts from the doctors on this thread on my numbers?
KidDoc
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AG
What is your LDL?
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
RightWingConspirator
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AG
Not sure which you're looking for, but I have a VLDL score of 12 and a DLDL score of 166.
DeepintheHeart06
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There isn't nearly as much data for statins and T1DM. If you want a more individual risk assessment consider a coronary calcium score. It will assess plaque within your heart arteries and can be compared to a database matched for age, sex, race and tell you where you rank. The youngest people in the database are 45, but regardless at younger ages your score should be 0. A non-zero score would be higher risk.

OasisMan - you are pretty strongly arguing that statin benefits are modest but instead you admittedly prescribe a drug that has zero evidence of any benefit. Not trying to be inflammatory but just curious how you reconcile this.
MouthBQ98
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What's an easy way to get a test these days? Do you have to go into a lab or doctors office?
lazuras_dc
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Any lab test now is easy and they have an advanced lipid panel that will show inflammatory markers and advanced lipid data like ldl particle count, lp(a) etc
OasisMan
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AG
DeepintheHeart06 said:


OasisMan - you are pretty strongly arguing that statin benefits are modest but instead you admittedly prescribe a drug that has zero evidence of any benefit. Not trying to be inflammatory but just curious how you reconcile this.
understandable

Statins IMO have a low benefit profile, and low+ side effect profile -- also newer evidence that it can increase risk of dementia (up to 2x), including PET scans that are similar to dementia patients

Leqvio for sure lowers "bad" cholesterol, low side effect, very well tolerated, and 1 less pill

I don't use it for primary prevention,
I don't try to convince pts of Leqvio over statins, I just point out evidence based articles and let them decide
lazuras_dc
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For anyone that's interested.

https://peterattiamd.com/why-a-recent-study-hasnt-shaken-my-faith-in-statins/?utm_source=weekly-newsletter&utm_medium=email&utm_campaign=220403-NL-statins&utm_content=220403-NL-statins-email-nonsubs-b
wbt5845
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I think doctors just fall into the habit of prescribing statins anytime your cholesterol is over 200.

For the vast majority of people who don't exercise and eat poorly, there's perceived to be little to no harm.

Mine bounces around 225-250. I now workout everyday and eat pretty clean, so I just tell my doctor no on statins. Never had an adverse reaction to them, just prefer not to take any more meds than are necessary.
Kool
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lazuras_dc said:

For anyone that's interested.

https://peterattiamd.com/why-a-recent-study-hasnt-shaken-my-faith-in-statins/?utm_source=weekly-newsletter&utm_medium=email&utm_campaign=220403-NL-statins&utm_content=220403-NL-statins-email-nonsubs-b
Thanks for posting. I TRY to follow Peter Attia, but his analyses can get super technical. In this particular case, I think he is saying that perhaps we are measuring the wrong molecule - we should measure Apolipporotein B instead of LDL. Definitely a meta analysis of 4.4 years is ridiculously short in order to try to determine risks associated with treatment versus non treatment with statins if the outcome is CV events.

I would think that anyone who has a significantly elevated lipid profile would want to then stratify their own cardiovascular risk with a further test - maybe that's a cardiac calcium score? - before deciding on whether avoiding a statin is the most prudent course to take. I don't think it would be wise to just look at those numbers and ignore them. Even perfectly "healthy" people who diet and exercise and maintain a normal weight are subject to CV events.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
lazuras_dc
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Agreed, he can definitely get into the weeds but it makes me research things and I *feel* like I'm smarter after listening to him or reading his articles.

I think Inflammation markers, Calcium score and also carotid ultrasound could provide some insight into risk. But I do think it's starting to be accepted that even young and "healthy" folks can have risk factors. The lipoproteins here are necessary but not causal is a way to think about it for me.
OasisMan
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unfortunately apoB and VLDL are almost never checked -- and b/c of this, i would venture to guess that most PCPs would not know what to do with the levels

statin trials tend to be in that duration, so thats all the meta-analysis could use -- lipitor 80 vs 10, lipitor vs placebo, lipitor vs zocor, lipitor vs pravachol, etc
--> heres a study w/ statins over 8yrs looking at association w/ cognitive impairment, confirmed w/ PET imaging

Quote:

Conclusions: Among subjects with early mild cognitive impairment and low to moderate serum cholesterol levels at baseline, lipophilic statin [includes lipitor] use was associated with more than double the risk of converting to dementia over eight years of follow-up compared with statin non-use, and with highly significant decline in metabolism of posterior cingulate cortex -- the region of the brain known to decline the most significantly in the earliest stages of Alzheimer's disease.


not a huge fan of random carotid ultrasound'ing (CUS) -- CUS is an inconsistent study due to technician technique, individual anatomy of the patient, how the patient is laying during the test, etc -- it really only checks 2 of the main 4 arteries that supply the brain -- and with those 2, it really only checks a small section (so you are missing the parts before and after) -- also I dont think PCPs know what to do with those test results -- and even in vascular neurology, the recs are controversial b/c the data is inconsistent (regarding primary prevention with carotid endarterectomy)
-- ive seen people have a CUS one day and it showed 70% stenosis, and then a repeat CUS the next day was negative
-- ive seen people have a negative CUS one day, and then a have a CTA neck that shows 70% stenosis
-- i understand why people like to get em, they like information -- just recognize the information could be wrong and thusly subsequent recs could be needless
-- at the same time, false negative CUS results could lead you to be undertreated -- for instance, if we saw plaque build-up on the carotids (in sections not seen by CUS), inside or outside the skull, or on the vertebrals, or the basilar --> this is just not seen on CUS
-- if you do get an abnormal CUS, possibly confirm w/ a CTA neck +/- head (assuming kidney function is fine) prior to medical optimization


i do like the thought of screening with biomarkers (serum, imaging) -- unfortunately tho, pills tend not to fix personal lifestyle habits
lazuras_dc
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I think the carotid ultrasound would be similar to calcium score in that if you get a negative result back it doesn't necessarily equate to disease free. But if you get a positive result back that would indicate further investigation or therapy. But you're right I bet technician technique will matter a lot and we shouldn't hang out hat on these tests.
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