New ways to lower cholesterol

A staggering 28 million adults in the United States have high cholesterol, meaning they have too many lipids (fats) in their blood.

That number, from the Centers for Disease Control and Prevention (CDC), doesn't even share the entire story. Though high cholesterol is a leading cause of heart attacks and strokes, the condition has no symptoms. Many people have no clue their cholesterol is too high.

A simple blood test can measure cholesterol levels, and the CDC recommends that "most healthy adults" have cholesterol levels checked every four to six years. The test measures LDL ("bad") cholesterol, HDL ("good") cholesterol, and triglycerides. (Those who have heart disease, diabetes, or have a family history of high cholesterol should have their cholesterol checked more often.)

Lifestyle changes are the first line of defense against high cholesterol — for good reason: Adopting a healthy lifestyle can drop high cholesterol by as much as 10%.

The American Heart Association (AHA) recommends following a diet featuring whole grains and plenty of produce while reducing intake of meat and sugar. Nutritional meals, regular exercise, avoiding tobacco, and maintaining a healthy weight, will go a long way to protecting your heart and arteries.

However, some patients will need additional help to manage their cholesterol levels, and their doctor may recommend further medical intervention, Northwell Health explains.

Cholesterol-lowering treatments

Methods for lowering high cholesterol have come a long way, says cardiologist Eugenia Gianos, MD, director of Women’s Heart Health at Lenox Hill Hospital and director of Cardiovascular Prevention for Northwell Health.

“Even as early as five years ago, there was only so much we could do for certain patients, and they’d still end up in the emergency room,” Dr. Gianos says. “They’d need repeated stents and bypass surgery, or suffered from multiple heart attacks or strokes.”

High levels of LDL cholesterol can lead to fatty deposits in the walls of arteries. That’s how heart disease can begin; as those deposits grow, they can impede blood flow and lead to blockages in arteries, resulting in heart attacks or strokes. Most cholesterol-lowering therapies are aimed at reducing LDL.

"To prevent heart disease, we must get patients' LDL as low as possible," Dr. Gianos says, and adds, "Thankfully, now we're in an era of prevention when we can offer far more advanced therapies."

Daily cholesterol medications

These medications are the first medical option for patients trying to lower their cholesterol. The drugs are most effective when patients combine them with a healthy lifestyle.

Statins: By slowing the liver's production of cholesterol while also increasing the ability of the liver to clear cholesterol, statins can reduce LDL levels by as much as 55 percent in some patients. Statins may also play a role in reducing inflammation and can help prevent strokes and heart attacks.

Ezetimibe: Another common cholesterol medication, ezetimibe interferes with the body's ability to absorb cholesterol in the gut, and it can lower levels between 15-20%. Patients can take this drug alone or with a statin to gain additional cholesterol-lowering benefits. Using the two types of therapies together after a heart attack may reduce the likelihood of another cardiovascular event.

Cholesterol-lowering injections

A more recent development, injections can be for patients who didn’t get adequate results from daily medications or they may provide an option that’s easier for patients to adhere to since the shots only need to be given once every few weeks or months.

PCSK9 inhibitors: Patients get this injection every two to four weeks. The inhibitors can reduce the risk of heart attacks, strokes, and death. This option can be more expensive and is limited to patients for whom statins and ezetimibe have been less effective.

Inclisiran: Another new injectable sold under the name Leqvio, Inclisiran may work better for certain patients. It can lower cholesterol and may work well for patients who have trouble adhering to a medication schedule; the maintenance injections are given every six months.

Blood filtering

LDL apheresis: Some patients have dangerously high cholesterol levels, and medication or injectables aren't enough to address the issue. A genetic condition known as familial hypercholesterolemia can trigger very high levels; other patients may need stronger measures due to a combination of high cholesterol and heart disease.

For these patients, a procedure called LDL apheresis can help: The plasma portion of the patient's blood is diverted through an apparatus that filters out LDL cholesterol and returns the plasma back to the body.

Patients must get the three- to four-hour treatment every two weeks for the rest of their life, but LDL apheresis can be lifesaving. The reduction in cholesterol also lowers inflammation and reduces the risk of artery damage and other cardiac issues.

More protection is on the way

One other very important risk marker is lipoprotein(a), a unique type of cholesterol that is linked to early heart disease and aortic valve stenosis — a condition in which a valve in the heart can't open fully. Identifying this risk factor is key in patients with early disease or when multiple family members suffer from heart disease, especially as new therapies are in development targeting this specific cholesterol and may significantly lower their heart disease risk.

Finding the right therapy will require a discussion with a cardiologist, Dr. Gianos says. Sometimes cost, side effects and the ease of taking a medication may have an impact on a patient’s treatment.

“For some patients, we may be able to connect them with something new in a clinical trial,” she says. “For others, we may need to take a larger perspective and conduct genetic tests and find out what role their family history may play in their treatment. It’s key for patients to understand how these factors, along with cholesterol levels, affect their cardiovascular health.”

This story was produced by Northwell Health and reviewed and distributed by Stacker.