Talking About Your Cholesterol Levels

Too much low-density lipoprotein (LDL) cholesterol, also called the "bad" cholesterol, can clog your arteries and make a heart attack or stroke more likely. Keeping levels of LDL cholesterol low is an important part of heart health.

If you have high LDL or total cholesterol levels, be sure to talk with your clinician about your personal risk — or chance — of developing heart disease.

Step 1: Know your risk of heart disease, heart attack or stroke.

The good news is that we have tools to help gauge the likelihood that someone might develop a heart attack or stroke or die from one over the short- and long-term.

It’s important information to have because it can help to guide treatment decisions, including if and when you might need start or intensify cholesterol-lowering medications – in addition to lifestyle changes. It can also motivate you to make heart-healthy choices a priority.

Adopting heart-healthy habits can be hard, but it can make a real difference. Still, don’t lose heart if you need help or it takes a few tries to successfully implement changes.

>> For certain people who are considered high risk, we know that statin therapy coupled with a heart-healthy lifestyle can help to lower that risk. 

You fall into these “high risk” categories if you have:

  • Diabetes
  • Very high LDL cholesterol levels (≥ 190 mg/dl)
  • Had a previous heart attack or stroke
  • Had bypass surgery to open blocked or narrowed arteries
  • Stents placed in your heart’s arteries to prop them open 

Because of this history, you’re much more likely to have a first or repeat heart event or stroke. You and your health care provider should focus on talking about ways to:

  • Step up efforts to live a heart-healthy life 
  • Make sure you’re on the right medication or combination of medications to lower your cholesterol 
  • Help you successfully take your medications over the long-term

>> If you haven’t had a heart attack, stroke or related procedure and  you’re between 40 and 75 years of age, ask about your 10-year risk score. 

Your clinician can take certain information about you and enter it into a calculator of sorts. This will then generate your personal risk score. This score is given as a percentage — the chance that you will have a heart attack or stroke or die from one of these events in the next 10 years. 

This risk estimator factors in: 

  • Age
  • Cholesterol
  • Blood pressure
  • If you’re male or female
  • Your race
  • If you have diabetes
  • If you smoke

So if you are an adult who doesn’t have heart disease and are 40-75 years old, you may fall into one of these groups:

10-year Risk Score
Low Less than 5%
Borderline 5% to less than 7.5%
Intermediate 7.5% to less than 20%
High Greater than 20%

 

Making Sense of Your Risk Score

Let’s say your 10-year risk score is 10%. That means that you have a 1 in 10 chance of having a heart attack or stroke or dying from one of these events in the next 10 years. In other words — all else being equal — 1 out of 10 people similar to you will have a heart attack or stroke, or die from one of these events, in the next decade.

“If you don’t know your 10-year risk of having a heart attack, stroke or dying from one, it’s very difficult to understand how much of that risk can be curtailed by taking a statin or making lifestyle changes," says Salim Virani, MD, FACC, and member of the 2018 Cholesterol Guideline writing committee. “Your clinician can help answer your questions.”

You can also find out your lifetime risk of heart disease, which can be an important motivator. That’s especially true if you’re young and may not have thought about what steps you can take today to prevent cardiovascular disease down the line.

>> Talk with your clinician about other factors that may make having a heart attack or stroke more likely — beyond what is included and accounted for in the 10-year risk score. 

Some examples include if you have:

  • A family history of heart disease or stroke, especially at younger ages
  • Chronic kidney disease
  • HIV
  • Certain inflammatory disorders (for example, rheumatoid arthritis or psoriasis)
  • Certain conditions during pregnancy (for example, high blood pressure during pregnancy)
  • Certain ethnic groups   

These are called “risk enhancers,” or things that could increase the likelihood of your suffering a heart attack or stroke beyond what would be: 

  • Expected for the average person or
  • Picked up by the 10-year risk score

Step 2: If there is still some doubt in your or your clinician’s mind about your risk and whether you should start a statin, consider coronary artery calcium (CAC) scoring.

This simple test is done with a computed tomography (CT) scan of the heart to look for calcium deposits in the heart’s arteries. The presence of calcium — and how much there is — is a marker of disease. 

Using CAC scoring helps you and your clinician refine your risk and decide if statin therapy should be started. But it’s only recommended for certain patients whose risk is unclear. 

Step 3: Understand when a medication to lower cholesterol might be needed and why.

Decisions about cholesterol-lowering medications should be guided by:

  • How likely you are to have a heart attack or stroke (your ASCVD risk) and ongoing discussions with your clinician 
  • Your goals and what matters most to you

It’s important to understand why you are taking a statin or other cholesterol-lowering therapy. For example:

  • Are you in one of the high-risk groups?
  • If not, what is your 10-year risk and what does that mean for your future heart health?
  • How much will taking a statin lower this risk? 

Playing an active role in the decision to start therapy to lower cholesterol is important. Doing so will help you feel comfortable with the decision and more likely to take medication that your health care provider may prescribe. As part of your discussion about medications, you should know and factor in:

  • Your risk 
  • The overall benefit of being on this therapy, including potential side effects
  • Any cost considerations
  • Where managing your cholesterol levels falls in terms of other conditions you are managing

Remember that judging how a medicine is working isn’t always about how you feel. You may feel OK, but still need to take a cholesterol-lowering medication.

“You and your clinician should agree on starting a medication and be sure to speak up if you are unsure as to why it’s being recommended.”  –— Salim Virani, MD, FACC

Risk Groups What We Know
If you are considered “high risk”; for example, you’ve had:
  • Previous heart attack or stroke
  • Stents placed
  • Bypass surgery
  • Very high LDL cholesterol levels
  • Diabetes
Statin therapy in addition to heart-healthy habits is advised, and the highest amount (dose) is generally better.
Your 10-year risk score Depending on your risk score, your clinician may recommend that you start taking a statin.
You have other risk factors or conditions that increase your risk beyond what we would know from standard cardiovascular estimators/tools. Talk with your clinician about all of the factors that may make heart disease, heart attack or stroke more likely.

You may be at greater risk than what would ordinarily be estimated by traditional risk estimators only and, therefore, you might need to consider starting a statin.

 

Step 4: Remember that a statin or other cholesterol-lowering treatment only works if you take it.

Tell your clinician about any concerns you have with taking a statin or other cholesterol-lowering medication. Some people are hesitant to take a new medication because of side effects they’ve heard about or stories  from other people they may know. 

Ask about: 

  • When and how to take your statin
  • If there are any food, beverages or medicines that can change the way it works
  • Side effects to watch for (Note: most side effects can be managed)
  • Who to call if you have questions 

Step 5: Feel empowered to take charge of your cholesterol and your risk for heart disease and stroke.

There are steps you can take to lower your risk of developing heart disease or having a stroke or the risk of having worsening cardiovascular health. Life is busy, and it might seem overwhelming but there are things you can do to mitigate your risk.

It’s also important to get repeat bloodwork over time. For example, after you’ve been on a statin for a few weeks (usually 6-8 weeks), it’s a good idea to repeat your lipid panel or blood tests to check cholesterol. These tests can help determine how well your medication is working. Treatment can be adjusted as needed. 

Questions to Ask Your Care Team

  • How does LDL cholesterol relate to my risk of heart disease, heart attack or stroke?
  • What can I do to live healthier? Are there people who can help (i.e. nutritionist, exercise therapist)?
  • Do I have to be on a statin or other cholesterol-lowering medication for the rest of my life?
  • Will the medication alone control my risk?
  • What is CAC scoring and when is it recommended?
  • I’ve heard there are side effects with statins. Is this true? Can these be managed?
  • I feel OK. Why do I need to take a/another medicine? 
  • Are there resources to help lower the cost of medications? 

< How Cholesterol Factors into Heart Disease Risk

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Published: November 2018
Medical Reviewers: Martha Gulati, MD, MS, FACC, FAHA, FASPC; Salim S. Virani, MD, FACC

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