Introduction

Reviews

Should You Take Medication to Lower Your Cholesterol?

Timothy B. McCall, M.D.

To help understand whether you should take drugs to lower your cholesterol, consider the case of a nurse named Margaret DeIulio. She was crestfallen when she got back her cholesterol results. It had risen from 232 to 254 despite her best efforts to lower the fat in her diet. As a nurse, Margaret knew the recommendations to “know your number,” and has followed her cholesterol closely for years.

Now she was worried sick about her risk of suffering a heart attack. I was working with Margaret at the time and had seen her study the nutrition labels on boxes of crackers to determine the fat content and watched her munch carrot sticks and non-fat rice cakes with her lunch.

Despite her elevated cholesterol, Margaret’s risk for heart attack is actually lower than most people’s. There is no history of premature heart disease in her family. Margaret’s mother, a one-time heavy smoker, died in her late 80s of emphysema. Margaret doesn’t smoke. She walks regularly, isn’t overweight and doesn’t have high blood pressure or diabetes. Her sole risk factor for heart attack is her high cholesterol level.

Because of the synergy between risk factors for heart attack—that is the multiplying effect of multiple risk factors—when you’ve only got one, your risk isn’t that great. That’s why I have a problem with the simplistic recommendation of well-intentioned public health experts to “know your number.” A more sensible recommendation is to view your cholesterol in context. If it’s 250 and if like Margaret it’s your only risk factor, I wouldn’t be overly concerned. If your father had a heart attack at the age of 40 I’d worry about a reading of 215.

When I reassured Margaret about her low risk for a heart attack, the furrows in her brow disappeared. I advised her to continue her low-fat diet and her walking program—sensible advice for everyone—but to try not to worry about it all. One thing is for sure, I’d would not recommend she take drugs to lower her cholesterol level.

When contemplating cholesterol-lowering medication, remember that the decision on cholesterol-lowering medication should reflect your overall constellation of risk factors for heart attack. The following appear to increase the risk of a heart attack:

• a family history of premature heart disease
• being a male
• elevated cholesterol
• low HDL “good cholesterol”
• elevated triglycerides (another form of fat in the blood)
• smoking
• diabetes
• high blood pressure
• a lack of exercise
• being overweight (probably only a mild risk factor)

Because of the multiplying effect on risk, the presence of several risk factors is of more concern than just one or two.

Another thing to consider is that the total cholesterol number gives only part of the picture. High levels of LDL “bad cholesterol” and low levels of HDL “good cholesterol” are more strongly correlated with heart attacks than elevations of total cholesterol. Some people have high total cholesterols but low overall risk because their HDL levels are so high.

At the time of her cholesterol reading of 258, Margaret’s HDL was 52, which is not bad, and her LDL level was only in the borderline elevated range. Margaret’s cholesterol problem, like Wagner’s music (according to Mark Twain), was not as bad as it sounds.

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