Beyond Cholesterol

Cardiovascular disease the number one killer in America is at the forefront of the battle that steals years away from many Americans. Men are hardest hit, but women are not immune. Postmenopausal women will suffer death from cardiovascular causes at a rate of one in two. Cardiovascular disease kills more Americans than all cancers combined. This goes for women also; heart attacks (acute myocardial infarction or AMI for short) will take the lives of more women then all the lung and breast cancer deaths combined. Researchers are still searching for the right answer and the right medicine. Cholesterol has been in the sights for years and considered the major culprit. But there is more to this story, it does not end with just this one etiology, it is multi-factorial. Other risk factors may have more of an impact on the coronary artery than just cholesterol. For example Homocysteine, C-Reactive Protein, Fibrinogen, Lipoprotein (a), and even Apoprotein A-1 and B impact cardiovascular health significantly and may even play a bigger role than “cholesterol.” Tackling these other risk factors would go beyond the scope of this article, but I will take apart the Cholesterol issue.

In the past the focus was on reducing total cholesterol and low-density lipoproteins (LDL-C) a subtype of cholesterol. The National Cholesterol Education Program (NCEP) set up guidelines where they recommend Total Cholesterol remain under 200 mg/dL and LDL-C under 100 mg/dL (recently changed from a value of less than 130 mg/dL). Drugs were developed to lower total and LDL-C and thus save lives. Come to find out the true hero is the high-density cholesterol (HDL-C) subunit of cholesterol. This type of cholesterol scavenges the “bad” cholesterol and thus does not allow plaque formation to occur which narrows the coronary arteries and results in AMI. One can even measure the 5 subclasses of HDL-C where H1 & H2 may be harmful while the larger HDL subclasses of H3, H4 & H5 are considered good and reduce risk. The true predictor for cardiac risk is not the total cholesterol or even the LDL-C, but the total cholesterol to HDL-C ration (TC:HDL-C). If this ratio is above 4.8 you are at increased risk to suffer from heart disease. Once a low HDL-C and/or high Total Cholesterol level is diagnosed it is important to implement treatment. Diet alone often fails, since the liver will make up what cholesterol you don’t eat. Several therapies exist, and it is more a matter of how aggressive you need to be and how well tolerated they are as to which you choose.

In a recent case study at the SLI a 36 year old male patient with a total cholesterol of 241 mg/dL, and LDL-C of 159 mg/dL and an HDL-C of 44 mg/dL prior to any therapy was given several regiments in an attempt to control his dyslipidemia. This patient was taking and continued to take a potent multivitamin and mineral supplement and the antioxidant coenzyme Q10 (25 mg daily). First was the very well tolerated and safe Inositol Hexanicotenate (which converts to niacin in the liver) 2000 mg and Garlic 500 mg daily and after 3 months the Total cholesterol was measured at 251, LDL at 150, HDL-C at 43. Not much of an improvement. This is seen in about 50% of subjects started on Inositol Hexanicotenate. The second trial was with Zocor 20 mg at bedtime (again coQ10 was continued at 50 mg per day to offset deficiencies that can occur with this drug) and after 60 days the results were as follows: Total Cholesterol 197, LDL-C 117, and HDL-C of 40. It is interesting to note that a recent study of 153 randomized patients with CAD and low HDL were given low dose Statin and niacin combination with and without antioxidants. The subjects taking antioxidants did not have a rise in HDL-C as did those who did not take an antioxidant cocktail which saw an increase in HDL of 42%. This is of importance when a patient is not responding to statin therapy and on concomitant antioxidant therapy. These were the best results so far.

Finally, because of complaints of muscle pain and the fear of “untoward effects” from the statin drug, the patient was tried on a “new” highly touted lipid-lowering agent called Policosonal (oxycosonal, a derivative of the waxy coating of sugar cane and considered a natural alternative). After 60 days the lipid profile was as follows: Total Cholesterol of 220, LDL-C of 139 and HDL-C of 39. A slight drop in the LDL-C and total, but not good enough. Finally Niacin (in the form of sustained release Niaspan) was attempted, but discontinued after 8 weeks due to constant flushing and pruritis (itching).

While the Inositol Hexinecotinate/Garlic and Policosonal therapies are considered “natural” they certainly were not better at achieving results. Zocor a potent (HMG-CoA reductase inhibitor [Statin] drug (when taken correctly and monitored for liver toxicity and in combination with coQ10 supplementation) is a very aggressive way to lower LDL and raise HDL-C (minimally). There are now low dose statin drugs in combination with niacin (truly the one drug/supplement shown to raise HDL-C the best) that show promise. Factors that may interfere with this may be very high dose antioxidant therapy and one must follow on a case-by-case basis.

Another approach not yet explored with this patient is a combination of herbals and nutrients known to lower cholesterol. This “shot gun” approach may yield better results than any one agent used alone. As this patient is placed on a regiment of lower dose niacin, policosanol, plant sterols, tocotrienols, guggulipid, phosphatidylcholine, oat bran, garlic and antioxidants, time will tell and I will keep you posted. As an integrative physician I use the safest or least harmful therapeutics first, but should they fail, I apply more traditional synthetic drugs to reach an endpoint that is known to save or extend life. Not all that is synthetic is evil as this case study demonstrates; one has to always consider the risk benefit ratio.