Dr. Stephen Sinatra - How to Determine if You Really Need a Statin

stephen_sinatra_136The standard lipid tests that most doctors order for you belong to the age of the dinosaurs.  They tell you the level of your total cholesterol, LDL and HDL.  Since 2007 I have been writing about a new generation of tests - one is called the Vertical Auto Profile (VAP) test, the other the Lipoprotein Particle Profile (LPP) test. (For more information on these tests go to: thevaptest.com and spectracell.com).

These tests, which are covered by Medicare ( in the U.S.) and most health insurance plans, break cholesterol down into fractions, appearances, and patterns, giving a much more accurate picture of what may or may not be a problem.  They have introduced the medical community to subgroups of lipoprotein particles and how their different sizes and patterns can play a role in the inflammatory degeneration of arteries. Recently I taught a continuing education course on anti-aging cardiology to 150 conventional doctors, including cardiologists.  Most of them didn't know these new tests existed and were extremely excited to hear about them.

For sure these analyses help make better sense out of the cholesterol confusion.  They break down the major cholesterol components and take you light years beyond generalizations like LDL cholesterol is the "bad cholesterol" and HDL cholesterol is the "good cholesterol."  The reality is much more complex.  It is not just about how high the LDL is, but what kind it is and how much of it you have. Ditto with HDL. 

Keep in mind that the liver ( where a good portion of your cholesterol is produced ) dispatches cholesterol throughout the circulatory system in the form of protein-wrapped fatty bundles called LDL.  As LDL travels through the system, the cholesterol is accessed and used by cells as needed.  Similarly, spent and oxidized cholesterol is picked up by HDL particles for return to the liver and subsequent excretion.

Looking closer at these particles, as the new tests do, reveals important discrepancies.  LDL particles, for instance, can be large or small.  It is the small, dense LDL particles that can readily enter into compromised arterial walls and stoke the inflammatory process.  Higher numbers of these LDL particles represent a higher risk.  Genetics play a major role here, and not diet as most people have been erroneously led to believe.

If you have significant numbers of these factors present, in the presence of cigarette smoke, mercury, lead, transfatty acids, insulin, homocysteine, radiation, the potential for arterial damage increases.  This is where I, as a cardiologist, become concerned, and particularly when there is a significant presence of Lp(a) - the most dangerous of these lipids and truly what we can refer to as "ugly cholesterol." 

This small, dense LDL entity is a major thrombotic factor.  It inflames the blood and makes it sticky.  Another small dense particle that has emerged with an inflammatory reputation is called RLP, short for remnant lipoprotein. It plays a role in the formation of plaque.

You want to have fewer of these subtypes and instead have more of what are called large, buoyant LDL. That kind of result suggests less of a risk. With advanced testing, two people with the same total measurement of LDL cholesterol may be at opposite ends of risk. One, with a predominance of small, dense LDL particles, may have three times the risk of someone with mostly large, buoyant LDL.

Similarly, there are significant differences among subgroups of HDL that relate to how well or not they execute removal of excess lipids.  Not all HDL is created equal.   You want to be high in the most functional HDL subgroup labeled 2B. The worse scenario, with this kind of testing, would be to have a predominance of small, dense LDL particles and low HDL 2B.   

What about your total cholesterol? you may be asking.  Well, it doesn't mean much unless you have very high cholesterol, with increased risk of stroke, and then it certainly behooves you to bring it down.  And you can readily do that with lifestyle modification, weight reduction, and eating a lot of good fiber.  I wouldn't recommend a statin drug unless you had evidence of arterial disease and were a male.  I have been very disappointed with the lack of results among women.

Here's what you have to remember if your standard cholesterol numbers are "high" and your doctor tells you to take a statin: Don't do it! Ask your doctor to follow up with one of the new tests that clarifies your individual cholesterol fractions.

If you are a male between 50 and 75 and have coronary artery disease, and the advanced test shows you have a predominance of small dense LDL, go for the statin drug.  It's a good idea.  Statin drugs are also anti-inflammatory and that's the powerful effect you are looking for, not the cholesterol-lowering activity.   Over 75, I wouldn't do it.  Too many downsides.

If you are a woman, and do not have unhealthy levels of inflammatory types of cholesterol and inflammatory substances such as homocysteine, fibrinogen, and C-reactive protein, I would pass on statins.  However, if you are a woman with arterial disease and have a profile of high inflammatory cholesterol and other substances, a statin may provide you benefit as an anti-inflammatory agent.

Dr. Stephen Sinatra, M.D., F.A.C.C., F.A.C.N.
Dr. Sinatra is a retired board-certified cardiologist who integrated conventional medical treatments for heart disease with complementary nutritional, anti-aging, and psychological therapies.
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Updated November 2010

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