Therapy for Lowering Cholesterol

In Three Risk Categories

The Goals for Lowering Cholesterol Vary From Person to Person

Have you ever wondered how your doctor sets your goals for lowering cholesterol? Television commercials give us the impression that there is a magic score that applies to everyone.

Now it is true that all of us should have cholesterol levels within certain parameters. But for the purpose of treatment your cholesterol goals are determined by your risk category.

For example, I might have a number of high cholesterol risk factors that you don’t have. (We will talk about what these risk factors are in a moment.) Because I exhibit certain risk factors my risk for coronary heart disease is higher than yours. It is important that I get my LDL cholesterol down. Your LDL levels might be the same as mine. But because you do not have these other risk factors it is not as important that you lower your LDL.

The truth is there are many factors your doctor must consider. Only then will you know how aggressive you should be about lowering cholesterol. The first thing to do is determine your absolute risk for developing coronary heart disease (CHD), or experiencing a CHD related heart event.

To get a better idea of what this means let’s take…

A Bird’s Eye View of the Three Risk Categories

In short a person will be classified in one of three categories for risk. In each category the goal for LDL cholesterol levels vary. You and I are placed into one of these categories based on the number of risk factors we have. The three categories are defined as…

  • Having coronary heart disease (CHD) or CHD equivalents
  • Having multiple risk factors
  • Having zero to one risk factor

If you are in the CHD equivalents category you have more than a 20% chance of having a CHD related heart event within the next 10 years. Because LDL cholesterol levels are closely tied to coronary heart disease it is most important for you to get your LDL down to the lowest level. Costs for therapy are less of a concern.

The main concern is to save your life. Therefore you should be aggressive about getting your LDL cholesterol below 100 mg/dL.

On the other hand, you may be a young person withno CHD risk factors. It is very unlikely that you will experience a CHD related event in the next 10 years even if your LDL is a bit high. Your goals for lowering cholesterol will not be as aggressive.

Having said this it is still important to keep your LDL cholesterol low. It just isn’t as critical in the short-term. It is unlikely your doctor is going to prescribe drug therapy.

In a moment we will look at each of these three risk categories in detail. But before we do I think it important to mention that…


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Are there health issues – in addition to your heart health – that concern you? Like…

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  • Your body holding on to too many toxins?
  • And chronic inflammation?
  • And pH and blood sugar imbalance?
  • And your elimination organs not working well?
  • And poor nutrition?
  •  And foods that stress your system?

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There Are Basically Two Ways to Reduce Cholesterol

So you need to reduce cholesterol. What do you do?

There are two approaches for lowering cholesterol. The first involves lifestyle changes and the second, drug therapy. Notice drug therapy comes second. That is not by accident.

Lifestyle alterations are preferred prior to drug therapy for multiple reasons.

In many cases lifestyle choices and changes are responsible for our deterioration in heart health.

In other words, we got ourselves into this mess. For example, a person who smokes cigarettes increases his risk for developing coronary heart disease. By quitting the patent reduces this risk.

A second reason lifestyle changes are preferred is because they can be more effective. If our choices have negatively affected our heart health then reversing these decisions can bring positive results.

Thirdly, drug therapy can be very expensive and can produce negative side effects.

Lifestyle changes are certainly the most cost effective and the most natural. Therefore, it is usually preferable to start with lifestyle changes and monitor the results. If the LDL goal is not achieved, only then should drug therapy be considered. (The particulars of lifestyle therapy and drug therapy are considered in detail elsewhere in the cholesterol section.)

Drug therapy and lifestyle modification therapy often work together. A better way of saying it is this… Lifestyle modification therapy should always be in effect. Sometimes drug therapy must be added to it to achieve certain short-term goals. The goal is to eventually discontinue drug therapy and continue lifestyle modification therapy.

When should we disregard lifestyle therapy? Never! We should always strive for optimal heart health.

Having spoken from my soapbox we can now return to the topic of the three risk categories and the appropriate therapy approaches for each. Let’s begin with the…

Highest Risk Category: CHD and CHD Risk Equivalents

If you had documented coronary heart disease, or CHD equivalents, you would be placed in the highest risk category. That means that the likelihood that you would suffer a CHD related heart event within the next ten years is greater than 20%.

In very practical terms it means that more than 20 out of every 100 persons in this risk group will suffer from CHD related heart trouble within the next decade. LDL cholesterol is very closely tied to the development of coronary heart disease. Therefore the LDL cholesterol goal for this group must be low (< 100 mg/dL), and the therapy to attain this goal must be intensive.

By the way, having CHD equivalents means you have certain factors that make your risk as high as if you did have coronary heart disease. These equivalent factors include…

  • Other forms of atherosclerosis (clogging of the arteries) including carotid artery disease, abdominal aortic aneurism or peripheral artery disease.
  • Diabetes
  • A combination of other risk factors that elevate one to a risk factor of greater than 20%.

To look at a few examples we need a guinea pig. I suppose you are handy.

Let’s suppose then, that you are in this CHD equivalents group and your LDL cholesterol levels are at or above 130 mg/dL. Intensive therapy involving lifestyle changes should be applied immediately. Further, other risk factors should be aggressively controlled.

Because patients in this category receive the most aggressive treatment...

It is often necessary to include LDL lowering drugs simultaneously with lifestyle adjustments.

The use of drugs is not the first choice because of their expense and potential side-effects. However, high LDL cholesterol in this risk group outweighs these concerns because of the high risk for long-term heart disease.

But let’s suppose for a moment that your LDL cholesterol is not quite 130 mg/dL. Let’s say it was somewhere in the range of 100 to 129 mg/dL. What would your doctor do?

In this case you are still in the highest category. However, your LDL cholesterol does not pose quite as much risk as in the previous example. You still need to apply intense lifestyle therapy.

Drug therapy, however, is a bit more optional. Your doctor may or may not choose to prescribe drugs in the short-term to reduce cholesterol.

Let’s consider one more scenario. Suppose you are in the CHD equivalent group but your LDL cholesterol levels are below 100 mg/dL. Your LDL goals have already been reached. Congratulations. No further drug therapy is necessary.

Keep in mind, however, you are still in the highest risk category. Lifestyle alterations should still be applied and maintained to keep LDL levels down. Also other risk factors should be kept in check and treated when appropriate.

As you can see, lowering cholesterol – especially LDL cholesterol - is always the main focus of treatment. There is an exception, however.

Some patients have what is called Metabolic Syndrome. For these folks an emphasis on weight reduction and increased physical activity may be the primary concern for treatment.

Some with Metabolic Syndrome receive treatment not designed to lower cholesterol as the primary goal. Because the cholesterol levels are marginal there may be more pressing issues to treat first.

For example, if the patient has elevated triglycerides or low HDL cholesterol primary attention may be directed to adjusting these risk factors before attempting to influence LDL levels.

The Next Risk Category: Multiple Risk Factors

I picked on you in the last series of examples. I suppose it’s my turn now.

Let’s suppose I do not have coronary heart disease or any CHD equivalent factors. I do however have at least two conditions that are connected to the development of coronary heart disease. What are the recommendations?

Well, as science would have it, the question is not that easily answered. I must first be categorized into one of two subgroups. Who is the guinea pig now?

The first subgroup includes folks like me. It is calculated that my risk for long-term CHD related heart trouble is no more than 20%. Because the long-term risk is a little lower than the highest group the LDL goal is not as low.

Keep in mind that the LDL goals are designed for therapy purposes. It does not mean that the ideal health goals for LDL are not lower. The current goals are benchmarks for making treatment decisions.

Of course LDL levels below 100 mg/dL is still the ideal. But for therapy purposes LDL goals in my subgroup are set at less than 130 mg/dL. (Remember that your LDL goals were set below 100 mg/dL.)

The design of therapy is not only to reduce long-term risk but short-term risk as well. If my LDL levels creep above 130 mg/dL then lifestyle changes should be applied for three months. If my LDL goal is not realized by that time then my doctor should consider prescribing LDL lowering drugs.

By the way, calculating percent risk for experiencing coronary heart disease or related heart trouble is not magic or guesswork. There exists a very precise tool for making these calculations known as the Framingham Point Scores.

These scores have come from studies related to the Framingham Heart Study begun in 1948. This was, and is, a landmark study which has revolutionized the way we evaluate heart health issues.

You can read more about the Framingham Heart Study by clicking here.

Let’s return to my troubles. Let’s suppose I am a bit healthier than originally thought. I still have at least two CHD risk factors. But it is calculated using the Framingham point scores that my 10-year risk for developing coronary heart disease is less than 10%. What then?

The first thing that will happen is I will be re-categorized into the second subgroup. Somehow that doesn’t make me feel any better. I especially do not feel any better when I discover my LDL goal has not changed either. It is still less than 130 mg/dL. I feel a bit slighted.

So what has changed? The primary aim has changed. Short-term risk is no longer a major consideration. Therapy now focuses exclusively on long-term risk. So if my LDL cholesterol levels are above 130 mg/dL then lifestyle changes should be administered. Drug therapy is now not considered necessary unless LDL levels rise above 160 mg/dL.

My doctor may still prescribe drug therapy to bring down LDL cholesterol below the 160 mg/dL in order to reduce long-term CHD related risk. Drug therapy beyond this point is not considered cost effective compared to the level of risk.

The Safest Risk Category: Single Risk Factor

Everybody must be categorized. It is the way of science. Unfortunately you and I missed out on the safest category. This category is of course our goal. The fortunate people in this risk category have no more than one risk factor for CHD according to the Framingham point scores.

Their risk for developing coronary heart disease (or related diseases) in the next ten years is less than 10%. Therefore LDL cholesterol goals are not nearly so aggressive.

Treatment is considered only when LDL levels rise above 160 mg/dL. Reducing long-term CHD risk is the goal in this category. If LDL rises above 160 mg/dL then lifestyle therapy should be administered and continued for at least three months. If LDL levels remain between 160 and 189 mg/dL, diet and lifestyle modifications should be continued and drug therapy should be considered.

Drug therapy is more likely to be administered if the patient…

  • is a smoker
  • has hypertension
  • has low HDL cholesterol
  • has a family history of premature coronary heart disease
  • has LDL levels of at least 190 mg/dL

As mentioned earlier, the primary goal of treatment in this group is reduction of long-term risk. High LDL cholesterol (in any risk group) accelerates the development of atherosclerosis. Atherosclerosis - as well as other related conditions - contributes greatly to death related to heart disease.

Let’s Talk About Optimal Heart Health for a Moment


All this detail may be helpful for us to get a handle on our risk for developing coronary heart disease. But the bottom line is your doctor is responsible for taking all these factors into consideration to recommend treatment options. Ultimately, however, it is your life.

It is not necessary to wait until you are in a high risk category to receive treatment. Since lifestyle alterations are the first line of attack in reducing long-term risk for CHD related heart disease, why wait?

Choose a heart healthy lifestyle now to avoid later complications. Heart disease is the number one killer of adults in many countries. Why not choose a healthier path before trouble starts?

After all, you and I are not merely concerned with heart disease. We are concerned with optimal heart health. We want the best heart health we can have. It is important to us. It is also important to those who love us.

If you have the time and inclination you can return to the main cholesterol page using the link below. From there you can follow all the links leading to more detail on cholesterol management including how to lower LDL cholesterol.

Of course like many of us you may not have much time. You may want to know what you can do for better heart health.

I suggest using this link to read the section on Lifestyle Changes.

You can read the rest when you have time. But by all means please do read. High cholesterol is serious business. Don’t be uninformed. 

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