My test results came back but neither my doctor nor I know how to interpret. Working to set up an appt. with the cardiologist he referred me to but wanted to see if anyone had any insight in the meantime. Anything not within range is noted in parentheses. I am 37m and high cholesterol runs in my family. Generally fit eating relatively healthy and exercising 4-5 days a week with weights and cardio. Anybody have experience with this test or insight on the results?

Total Cholesterol: 291 (classified as high)
Triglycerides 99
HDL Cholesterol: 75 (classified as high)
LDL Cholesterol: 196 (classified as high)
HDL Particle Size: 9.7
VLDL Particle Size: 40.3
LDL Particle Size: 22.2
Large HDL Particle No: 13.2
Small LDL Particle No: less than 165
LDL Particle No: 2031 (classified as very high)
HDL Particle No: 32.8 (just below the preferred level of 33)
Large VLDL Particle No: less than 1.5

You need to be on a high intensity statin therapy. I'm no cardiologist (hopefully our resident one chimes in), but from my limited knowledge, you have both a large number of LDL particles, as well as the cholesterol content of those LDL particles is high. Your HDL is reasonable, but I don't think it's high enough to confer protective effects.

I would almost assuredly put you on high dose Crestor, probably combine it another agent as well depending on how your respond to Crestor.

Does your family just have high cholesterol? Or do they have cardiovascular disease? Peripheral vascular disease? Strokes? Etc. What is your current diet like? Do you also have high blood pressure? Any evidence of insulin resistance? I think that'll determine next steps.

I'm not a fan of coronary calcium CT scans in young people, but if you have a family history of early MI, I would consider it in you. But that would be much better if discussed with cardiology. I'm just a health and fitness nerd that dabbles in medicine - or vice versa.

Your PCP doesn't know how to interpret?? I'd find a new one.

In the mean time here's some info you can increase your own personal IQ on the subject. Dr. Peter Attia has a wealth of knowledge on this stuff and has a multi part deep dive into cholesterol

https://peterattiamd.com/the-straight-dope-on-cholesterol-part-i/

For further insight , did you get an ApoB or Lp(a) ?

Particle count and total apoB essentially give you more information than the standard ldl-c (calculated)


Interestingly enough this article just came out today from Attia

https://peterattiamd.com/tools-to-stop-cad/

bigtruckguy3500 said:

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You need to be on a high intensity statin therapy. I'm no cardiologist (hopefully our resident one chimes in), but from my limited knowledge, you have both a large number of LDL particles, as well as the cholesterol content of those LDL particles is high. Your HDL is reasonable, but I don't think it's high enough to confer protective effects.

I would almost assuredly put you on high dose Crestor, probably combine it another agent as well depending on how your respond to Crestor.

Does your family just have high cholesterol? Or do they have cardiovascular disease? Peripheral vascular disease? Strokes? Etc. What is your current diet like? Do you also have high blood pressure? Any evidence of insulin resistance? I think that'll determine next steps.

I'm not a fan of coronary calcium CT scans in young people, but if you have a family history of early MI, I would consider it in you. But that would be much better if discussed with cardiology. I'm just a health and fitness nerd that dabbles in medicine - or vice versa.

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Appreciate the feedback. History of high cholesterol on my mom's side with her dad having/surviving a heart attack in his 50's. Negative on your other questions. Diet isn't as good as I probably think it is. Starting today I'm strictly eating whole grains, fish/chicken, veggies, and fruits/nuts. No idea on the insulin resistance, I'll ask my cardiologist when I meet with him.

lazuras_dc said:

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For further insight , did you get an ApoB or Lp(a) ?

Particle count and total apoB essentially give you more information than the standard ldl-c (calculated)


Interestingly enough this article just came out today from Attia

https://peterattiamd.com/tools-to-stop-cad/

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I did not, I'll talk to the cardiologist about an ApoB when we meet. Thanks for sharing the article. I just started his book "Outlive" and have learned a lot over the past few days already from watching some of his Youtube content.

Have you had basic blood work like a fasting glucose, or an A1C? If any evidence of either of those being elevated, it will compound risk of elevated cholesterol. Same with high BP, smoking, inflammation, etc.

I believe LDL particle number, which was measured, and ApoB can be used to give you a similar insight into atherogenic risk. Almost like surrogates for each other, but not quite. Lp(a) is [currently] a non-modifiable risk factor as far as I'm aware. So not really measured much. Some new drugs are being developed for it, and I've been seeing a lot of Facebook Ads for getting it measured for free locally - I think the companies are looking for trial participants.

Either way, will be interesting to see what cardiology says.

Yea right now Lp(a) is not realistically modifiable by the average patient but it can give insight into overall risk. Ie like myself.

I have normal parameter lipoprotein numbers but off the charts high Lp(a) so I have to more seriously consider a statin or other lifestyle modifications to get my other #s lower in the "normal Range" than someone who has normal or low lp(a).

I would start out by saying that primary prevention of cardiovascular disease is a complex equation. There are tons of markers/tests out there (lipid panel, microparticles, ESR, CRP, Lp(a), ApoB, homocysteine, etc). All of these have at least some data behind them, but there is no one test that gives you the answer. I often see people check different markers, effectively searching for 1 to be normal and then use that as justification to say they don't need treatment. So I caution against that.

With that being said, you have high cholesterol and it's not just "a little" high. But you are still young without any strong family history of premature CV disease. I would check your Lp(a) and ApoB levels, basically trying to better establish a risk profile. If those are elevated then I would recommend starting statin therapy.

If those are normal, then in my practice it turns into more of a conversation about how aggressive you want to be about prevention. With the age card, you could work aggressively on diet/exercise and continue to follow this over time. But I would say that based on your numbers, I would not expect you to be able to lower your cholesterol to really good levels by diet/exercise alone. It would truthfully be more about just delaying and deciding when is the right time to start meds.

I should also add that a coronary calcium score wouldn't hurt, but is unlikely to really be that helpful at your age.

And there are some drugs that have been shown to lower Lp(a) levels. But these are still at the research level, and more importantly, it isn't known if that truly results in reduced CV events. It is early stages, so it will be several years before we have any of those answers. But some promising work being done.

DeepintheHeart06 said:

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I would start out by saying that primary prevention of cardiovascular disease is a complex equation. There are tons of markers/tests out there (lipid panel, microparticles, ESR, CRP, Lp(a), ApoB, homocysteine, etc). All of these have at least some data behind them, but there is no one test that gives you the answer. I often see people check different markers, effectively searching for 1 to be normal and then use that as justification to say they don't need treatment. So I caution against that.

With that being said, you have high cholesterol and it's not just "a little" high. But you are still young without any strong family history of premature CV disease. I would check your Lp(a) and ApoB levels, basically trying to better establish a risk profile. If those are elevated then I would recommend starting statin therapy.

If those are normal, then in my practice it turns into more of a conversation about how aggressive you want to be about prevention. With the age card, you could work aggressively on diet/exercise and continue to follow this over time. But I would say that based on your numbers, I would not expect you to be able to lower your cholesterol to really good levels by diet/exercise alone. It would truthfully be more about just delaying and deciding when is the right time to start meds.

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Good stuff, I appreciate your input! Meeting with a cardiologist in a few weeks and started taking my prescribed statin in the meantime. Do you have a recommended diet?

DeepintheHeart06 said:

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I should also add that a coronary calcium score wouldn't hurt, but is unlikely to really be that helpful at your age.

And there are some drugs that have been shown to lower Lp(a) levels. But these are still at the research level, and more importantly, it isn't known if that truly results in reduced CV events. It is early stages, so it will be several years before we have any of those answers. But some promising work being done.

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Are these newer drugs just the PCSK9-inhibitors? I was all excited for these, but my cardiologist didn't think I qualified when they first came out seven or eight years ago. I've been on 2000 mg of niacin since I was in my early 30s. It kind of sucks.

Plant based is probably the best but that's really hard. More realistic is something similar to the Mediterranean diet.

I should point out that everything I've said are my thoughts. Admittedly you could ask 10 cardiologists and maybe get 3-4 different opinions about this stuff.

PCSK9i are great drugs, but don't affect Lp(a). The Lp(a) drugs are research only at this point and some include Pelacarsen, Olpasiran, and Zerlasiran.

Not sure your individual circumstances but the data behind Niacin really isn't that good. I would say it's generally not worth the side effects.

Have you had a coronary calcium scan? I have high cholesterol (genetically) as well. My cardiologist is not concerned since I have 0% calcified arteries.

Out of curiosity, why do you think "plant based is probably best" is your gut reaction?

DeepintheHeart06 said:

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Plant based is probably the best but that's really hard. More realistic is something similar to the Mediterranean diet.

I should point out that everything I've said are my thoughts. Admittedly you could ask 10 cardiologists and maybe get 3-4 different opinions about this stuff.

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Anecdotally, the people I've seen who have gone plant based have lowered their cholesterol numbers significantly. Which is interesting you may say because dietary cholesterol really should'nt have an effect on blood cholesterol #s. But the triglycerides/ saturated fats modify blood levels of cholesterol at the level of the liver and interaction with HDL. So I think that's where the mechanism of the vegetarian diet plays on helping blood levels of cholesterol.

Cowboy Curtis said:

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Have you had a coronary calcium scan? I have high cholesterol (genetically) as well. My cardiologist is not concerned since I have 0% calcified arteries.

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Any non zero CAC score signifies disease but a 0 does not necessarily rule it out completely. You can have atherosclerotic changes prior to seeing changes on the CAC score.

I am certainly not advocating for this as I stopped it myself, but about 10 years ago, I was doing hard-core ketogenic diet, and my cardiologist gave me hell for it, but then he was literally shocked by my advanced, lipid panel and how good it was when I was on it.

I'm curious though, bc I've seen guys like Dr. Paul Saldino (carnivore diet) and he talks about his #s being off the charts. But his claim is that because other factors and variables such as inflammation and insulin sens.and that just a high LDL number itself is not anything to worry about. And of course apoB and ldl particle number are going to be a closer proxy for risk than ldl-c

lazuras_dc said:

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I'm curious though, bc I've seen guys like Dr. Paul Saldino (carnivore diet) and he talks about his #s being off the charts. But his claim is that because other factors and variables such as inflammation and insulin sens.and that just a high LDL number itself is not anything to worry about. And of course apoB and ldl particle number are going to be a closer proxy for risk than ldl-c

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Interesting that this seems to contradict the article Attia came out with (you linked above) regarding APoB

Seems Attia thinks APoB is part of the problem and Saladino thinks APoB shows up to help repair arteries (hence the high levels seen in people with CVD)