Most of us love traditions. As I write these words, I have just finished cleaning up the final dishes from our Thanksgiving holiday, with family and friends gathered around a bountiful table and expressing gratitude. I’m for tradition as much as anyone.
However, there are places that tradition is harmful. In western medicine, the desire to hold onto the “traditional” perspective and practice can be harmful and injurious to our patients if it keeps us from moving to better practices and recommendations.
Many such examples exist within medicine, but perhaps none is so ingrained as the way we test cholesterol. When we think of being responsible for our health, we are encouraged to “know our numbers” and keep our “healthy cholesterol high” and our “lousy cholesterol low.” I have spoken these words to patients many times, as this is the dogma with which I was “raised” as a physician.
I bring this up because it is time for change. Two of the largest studies on cholesterol and heart disease (The Framingham Offspring Study and the Mesa Trial) demonstrate the extremely poor correlation between our LDL-C (what we are used to seeing when our doctor does our yearly cholesterol testing) and the incidence of cardiovascular events (like heart attacks or strokes). This discrepancy is most evident in those who have problems with blood sugar control. In people who have early signs of a trend towards diabetes (triglycerides over 80, HgbA1c over 5.5, insulin over 10, blood sugar over 100 or that rises more than 30 points after eating a meal), the LDL-C is almost worthless as a predictor of heart events. And yet this is the test we predominately have performed with our yearly blood work.
What should we do instead?
Evidence supports testing the number of particles of LDL cholesterol and our insulin levels as the two most predictive tests to indicate risk. In addition, testing for inflammation in our blood vessels (with tests like hsCRP, LpPLA2, and Myeloperoxidase) helps predict where we are in the spectrum of heart disease progression.
So the list to request from your doctor should include:
- Advanced lipid particle testing (NMR is the most accurate). If your doctor cannot order this, then ask for an apolipoprotein B test which is a more commonly available screening test to know if you should continue to pursue the advanced testing. Apo-B is a receptor that exists on each particle of LDL cholesterol and a level greater than 90 means that you have elevated LDL particles.
- Insulin and blood sugar level; and
- Inflammatory testing such as hsCRP and LpPLA2.
A recent assessment published by the Journal of Medical Economics shows that by improving cardiovascular disease risk assessment we could reduce heart attacks and strokes by 10%. The health care cost savings from doing these advanced tests instead of a traditional cholesterol panel have been estimated at $187 million. I’d say it is time to embrace a new paradigm in heart health.
Dr. Brossfield is the medical director at the Eisenhower Wellness Institute and can be reached at (760) 610.7360. EWI is offering an Integrated Heart Health Workshop on March 19th that will include advanced cholesterol and inflammation testing. Please call for details and registration.